USFWS Form 3-177 (Rev. 10/2017)OMB Control No. 1018-0012Expires 09/30/2019

U.S. FISH AND WILDLIFE SERVICE DECLARATION FOR IMPORTATION

OR EXPORTATION OF FISH OR WILDLIFE1. Date of Import/Export: (mm/dd/yyyy)

2. Import/Export License Number:

3. Indicate One: _____ Import _____ Export

4. Port of Clearance: ______________________

5. Purpose Code: __________

6. Customs Document Number (s)

7. Name of Carrier:

8. Air Waybill or Bill of Lading Number:Master: ______________________________

House: ________________________________________

9. Transportation Code: ______________

_________________ _____________________ License # State or Province

10. Bonded Location for Inspection:

11. Number of Cartons Containing Wildlife:

12. Markings on Cartons Containing Wildlife:

13a. (Indicate One) (Complete name/U.S. address/telephone number/e-mail address)_____ U.S. Importer _____ U.S. Exporter

13b. Identifier Number: _________________ ID Type: ________________

14a. (Indicate One) (Complete name/foreign address/telephone number/e-mail address) _____ Foreign Importer_____ Foreign Exporter 14b. Country Code

__ __

14c. Identifier Number: _________________ ID Type: ________________

15a. Customs Broker, Shipping Agent or Freight Forwarder:(Complete business name/address/telephone and fax number/e-mail address) 15b. Identifier Number: _________________ ID Type: ________________

15c. Contact Name: ______________________________________________

Species Code

(Official Use Only)

16a. Scientific Name

------------------------------------------------------------16b. Common Name

17a. Foreign CITES Permit Number

----------------------------------------- 17b. U.S. CITES Permit Number

18a Description Code

--------------------- 18b Source

Code

19a Quantity/Unit

------------------- 19b. Total

Monetary Value

20. Countryof Species

Origin Code(ISO Code)44284428

21. Venomous

Live Wildlife Indicator

(Check if yes)

Knowingly making a false statement in a Declaration for Importation or Exportation of Fish or Wildlife may subject the declarant to the penalty provided by 18 U.S.C. 1001 and 16 U.S.C. 3372(d)

22. I certify under penalty of perjury that the information furnished is true and correct:

_________________________________ _________________ Signature Date

________________________________________________________________________ Type or Print Name

For Official Use OnlyAction/Comments:

Wildlife Declared: ___Yes ___ No

Wildlife Inspected:None/ Partial / Full

See Reverse Side of this Form for Required Notices

Address Here Address Here

NOTICES

PRIVACY ACT STATEMENT

Authority: The information requested is authorized by the Endangered Species Act (ESA)(16 U.S.C. 1531-1544), Title 50, Parts 14, 15, 16, 17, 18, 21, 22 and the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES) [TIAS 8249, 27U.S.T. 1087], 50 CFR 23.

Purpose: The ESA makes it unlawful to import or export fish, wildlife, or plants without filing a declaration or report deemed necessary for enforcing the ACT or upholding CITES (see 16 U.S.C. 1538 (e)).

Routine Uses: The collected information is used to provide information about imports or exports, including products and parts, to facilitate en-forcement of the Act and other wildlife laws and regulations including the provisions of CITES. The information enables the Service to enforce any regulations that pertain to the wildlife contained in a shipment. We also use the information as an enforcement tool and management aid to monitor the international wildlife market and detect trends and changes to the trade of fish, wildlife, and wildlife products. More information about routine uses can be found in the Systems of Records Notice, Permits System, FWS-20.

Disclosure: The information requested in this form is voluntary. However, submission of the requested information is required to enforce any regu-lations that pertain to the wildlife contained in the shipment. Failure to provide the requested information may be sufficient cause for the U.S. Fish & Wildlife Service to deny the import or export of wildlife.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects required information about imports or exports, including products and parts, to facilitate enforcement of the Act and other wildlife laws and regulations including the provisions of the Convention on International Trade in Endangered Species of Wild Fauna and Flora. Information collected is also used to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information requested in this form is purely voluntary. However, submission of requested information is required in order to enforce any regulations that pertain to the wildlife contained in the shipment. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the import or export of wildlife. According to the Paper-work Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection of information and assigned Control No. 1018-0012.

ESTIMATED BURDEN STATEMENT

We estimate the public burden to complete this form to be 15 minutes by hand, or 10 minutes electronically, including time for reviewing instruc-tions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803. Please do not send your completed form to this address.

USFWS Form 3-177 (Rev. 10/2017)OMB Control No. 1018-0012Expires 09/30/2019

U.S. FISH AND WILDLIFE SERVICE DECLARATION FOR IMPORTATION

OR EXPORTATION OF FISH OR WILDLIFE

Species Code

(Official Use Only)

16a. Scientific Name

------------------------------------------------------------16b. Common Name

17a. Foreign CITES Permit Number

----------------------------------------- 17b. U.S. CITES Permit Number

18a Description Code

--------------------- 18b Source

Code

19a Quantity/Unit

------------------- 19b. Total

Monetary Value

20. Country of Species

Origin Code (ISO Code)44284428

21. Venomous

Live Wildlife Indicator

(Check if yes)

Knowingly making a false statement in a Declaration for Importation or Exportation of Fish or Wildlife may subject the declarant to the penalty provided by 18 U.S.C. 1001 and 16 U.S.C. 3372(d)

22. I certify under penalty of perjury that the information furnished is true and correct:

_________________________________________ _________________ Signature Date

___________________________________________________________________________________ Type or Print Name

For Official Use Only

See Reverse Side of this Form for Required Notices

13. Name of U.S. Importer or Exporter:

8. Air Waybill or Bill of Lading Number: Master: ______________________________ House: ________________________________________

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