Self-issued Certificate of Origin Form for Transport and Possession of Untreated Firewood - New York

This printable "Self-issued Certificate of Origin Form for Transport and Possession of Untreated Firewood" is a document issued by the New York State Department of Environmental Conservation specifically for New York residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

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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 (Village, Town or City):
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 210.45
of the Penal Law.
Printed Name of Transporter: ______________________________________________
Signature of Transporter: __________________________________________________
Date: _______________________
Print Form
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 (Village, Town or City):
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 210.45
of the Penal Law.
Printed Name of Transporter: ______________________________________________
Signature of Transporter: __________________________________________________
Date: _______________________

Download Self-issued Certificate of Origin Form for Transport and Possession of Untreated Firewood - New York

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