DESIGNATED HANDLER’S REPORT FOR POTATO RESEARCH AND PROMOTION ACT

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FIRST HANDLER’S REPORT FOR HONEY PACKERS AND IMPORTERS RESEARCH, PROMOTION, CONSUMER EDUCATION, AND INDUSTRY INFORMATION ORDER
                                                                                                                                                                                     OMB #0581-NEW







 Name: ____________________________________________________________
 Company Name: ___________________________________________________   Tax ID# or SS#: ___________________
 Address:  ___________________________________________________________________________________________
 City: ___________________   State: ____________     Zip Code: _____________    E-Mail: _________________________
 Phone No.: ______________________         Fax No.:________________      Web-site: _____________________________
 PERIOD COVERED BY THIS REPORT:                                                                                             DATE OF LAST REPORT:

FOR ADDITIONAL SPACE, YOU MAY ATTACH YOUR OWN SEPARATE SHEETS.  For questions about completing this report call (XXX) xxx-xxxx
 SECTION 1:  This section represents all assessable honey or honey products.
1.) LIST POUNDS OF HONEY OR HONEY PRODUCTS OF YOUR OWN PRODUCTION HANDLED:             ____________________

2.)  LIST POUNDS OF HONEY OR HONEY PRODUCTS PURCHASED FROM PRODUCERS:
            List the name and address of each producer along with the corresponding pounds purchased from each producer.
         ________________________________________________________________________             _________________
         ________________________________________________________________________             _________________
         ________________________________________________________________________             _________________
         ________________________________________________________________________             _________________
         ________________________________________________________________________             _________________
     
           TOTAL ALL POUNDS FROM 1 AND 2 ABOVE.                                                                                        
            
TOTAL AMOUNT OF ASSESSMENTS DUE:   Assessment of $0.xxx per pound is due with this report.                                  x  0.xxx                              

SECTION 2:  
    1.) LIST POUNDS OF HONEY OR HONEY PRODUCTS PURCHASED FROM OTHER FIRST HANDLERS, OR IMPORTERS:
List each handler’s name and address along with the corresponding pounds.  These are honey or honey products purchased on which the assessment has already been paid by the supplier.
________________________________________________________________________            _________________
________________________________________________________________________            _________________
________________________________________________________________________            _________________
________________________________________________________________________            _________________

    2.) LIST POUNDS OF HONEY OR HONEY PRODUCTS YOU HAVE IMPORTED                              ___________________
(Assessments have already been paid)
CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.xxx per pound on all honey or honey
products listed in section 1 handled during this reporting period for which I am required to pay the assessments as the first handler.  The assessments on the pounds reported in section 2 
have been reported and remitted by others for my account.  I will submit verification of the above upon request.

								
								SIGNATURE
__________________________________
DATE								TITLE 


Please Mail To:  Honey Packers and Importers Board
Street, City, State, Zip Code


This report is required by law [7 U.S.C. 7416, 7 CFR Part 1212.52 and 7 CFR Part 1212.70].  Failure to report can result in a fine of not less than $1,000 or more than $10,000  for each such violation.  Each such violation shall be deemed a separate violation.  The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, Section 1001 United States Code, which provides for the penalty of a fine of $10,000 or imprisonment of not more than five years, or both.

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 0581-NEW.  The time required to complete this information collection is estimated to average 30 minutes 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.  The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (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 to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C.20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.