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NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION ALBANY NEW YORK 12233 Self-Issued Certificate of Origin for Transport and Possession of Untreated Firewood In accordance with ECL Part 192. 5 Firewood Restrictions to Protect Forests from Invasive Species persons who cut and transport Untreated Firewood from a New York source for personal use must complete and possess this Self-Issued Certificate of Origin from the Department of Environmental Conservation. 1. Name of transporter 2. Street Address City State Zip Code 3. Origin of transported firewood Village Town or City 4. Destination of firewood being transported 5. Approximate volume being transported cords face cords cubic feet truckload etc* I understand that this Untreated Firewood shall not be moved more than 50 miles from it s origin the village town or city where the trees were grown as determined according to the regulation. I further understand under the regulation that no person shall transport Untreated Firewood into New York State from any other State or country. I hereby affirm that under penalty of perjury that information provided on this form and all attachments submitted herewith is true to the best of my knowledge and belief* False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210. Name of transporter 2. Street Address City State Zip Code 3. Origin of transported firewood Village Town or City 4. Destination of firewood being transported 5. Approximate volume being transported cords face cords cubic feet truckload etc* I understand that this Untreated Firewood shall not be moved more than 50 miles from it s origin the village town or city where the trees were grown as determined according to the regulation. Destination of firewood being transported 5. Approximate volume being transported cords face cords cubic feet truckload etc* I understand that this Untreated Firewood shall not be moved more than 50 miles from it s origin the village town or city where the trees were grown as determined according to the regulation. I further understand under the regulation that no person shall transport Untreated Firewood into New York State from any other State or country. I further understand under the regulation that no person shall transport Untreated Firewood into New York State from any other State or country. I hereby affirm that under penalty of perjury that information provided on this form and all attachments submitted herewith is true to the best of my knowledge and belief* False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210. Name of transporter 2. Street Address City State Zip Code 3. Origin of transported firewood Village Town or City 4. Destination of firewood being transported 5. Approximate volume being transported cords face cords cubic feet truckload etc* I understand that this Untreated Firewood shall not be moved more than 50 miles from it s origin the village town or city where the trees were grown as determined according to the regulation. I further understand under the regulation that no person shall transport Untreated Firewood into New York State from any other State or country.

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