FAS0930 (English Version)

Form Approved - OMB No. 0551-0040
U.S. DEPARTMENT OF AGRICULTURE
Foreign Agricultural Service

FAS-930
(05-21-04)

TRADE ADJUSTMENT ASSISTANCE (TAA) FOR FARMERS

PETITION FOR CERTIFICATION AND ELIGIBILITY FOR A GROUP OF PRODUCERS
NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The
authority for requesting the following information is the Trade Adjustment Assistance for Farmers, (Pub. L. 107-210). The information will be used to determine
program eligibility. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in denial of program benefits. This
information may be provided to other agencies.
According to the Paperwork 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 valid OMB control number. The valid OMB control number for this information collection is 0551-0040 The time required to
complete this information collection is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Completed petition must be submitted by January 31
and faxed or emailed or mailed to addresses listed below.

Deadline for petition submission is January 31 by one of the following methods:

FAX

(202) 720-0876

EMAIL

or

[email protected]

1. Name of Authorized Representative or Primary Contact

or

ADDRESS
U.S. Department of Agriculture
Import Policies and Programs Division/FAS
1400 Independence Ave., S.W.
Stop 1021
Washington, DC 20250-1021

2. Name and Business Address (Including City, State, and Zip Code)

3. Telephone Number (Including Area Code)

4. Fax Number (Including Area Code)

5. E-Mail Address

6. This petition is made on behalf of the following producers: (Use separate sheet for additional producers)
A.
Name of Producers

B.
Mailing Address

C.
Telephone No.
(Including Area Code)

D.
E-Mail Address

7. COMMODITY INFORMATION:
A. Description of the raw (excludes processed) agricultural commodity:
(e.g., fresh raspberries)

B. Competing Imported Commodity's Harmonized Tariff Schedule (HTS)
Number (HTS can be found at: http:/www.usitc.gov/affairs.htm)

C. This petition is for the most recent marketing year for the commodity beginning in

and ending
(month/year)

(month/year)

D. Check whether the certification is to cover a commodity produced nationally or in an "impacted" area (state or states):
National

State(s) (list):

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual
orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large
print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten
Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.

FAS-930 (05-21-04) Page 2
8. If Item 7D "National" is checked, provide the national average annual price for the most recent marketing year and the 5 preceding
marketing years. If Item 7D "State(s)" is checked to indicate that the petition is for an impacted area, provide the relevant average
price for the most recent marketing year and the 5 preceding years, and specify the months being averaged if the price is for less
than 12 months (seasonal price).
NOTE: Use Official data if available. The Department's National Agricultural Statistical Service (NASS) has national price data
available for many raw agricultural commodities. That information can be found at: www.usda.gov/nass. You must state the source
of your price data. If you do not use official data, you must provide contact information for verification purposes and supporting
documentation to show how your price was calculated.
A.
Marketing Year
Most recent:

B.
Average Annual Price

$
Provide prices for the 5 years
prior to the most recent
marketing years. Beginning
with the most recent.

C.
5-Year Average Annual Price
1 Year ago

$

2 Years ago

$

3 Years ago

$

4 Years ago

$

5 Years ago

$

9. Basis for request for adjustment assistance. Please explain or attach any documents, which show how increased imports have
affected the national price of your product during the most recent marketing year. In your description include any other factors
which may also have contributed to lower producer prices.

10A. SIGNATURE OF AUTHORIZED RESPESENTATIVE
OR PRIMARY CONTACT

10B. TITLE

10C. DATE SIGNED