FV-258-1 National Peanut Board First Handler's Report

NOTE: See reverse for instructions.

FORM APPROVED - OMB NO. 0581-0093

NATIONAL PEANUT BOARD

PEANUT PROMOTION, RESEARCH, AND INFORMATION ORDER

(7 CFR 1216) FIRST HANDLER'S REPORT

TELEPHONE
code)

NAME OF HANDLER
NAME
OF
COMPANY

BUSINESS/

NO.

(Include

area

HANDLER NO.

MAILING ADDRESS (Number, Street, City, State, ZIP
Code)

PART A:
REPORT
MONTH:

OF

PEANUTS

HANDLED

DURING

CURRENT

MONTH

LOAN ACTIVITY

YEAR

MARKET ACTIVITY

TOTAL VALUE SEGMENT
TOTAL R & P DEDUCTION

$_______________

SUBTOTAL OF ASSESSMENTS (A)

PART B: USE THIS SECTION TO SHOW ANY CHANGES FOR PREVIOUSLY REPORTED LOADS.
DATE OF PREVIOUS REPORT:
YEAR

MONTH

MARKET ACTIVITY

LOAN ACTIVITY

TOTAL VALUE SEGMENT
TOTAL R & P DEDUCTION

SUBTOTAL OF CHANGED ASSESSMENTS (B)

$(+ OR -) _________________

TOTAL OF ASSESSMENTS (A & B)

$ _________________

PART C: ON A SEPARATE SHEET, PROVIDE THE FOLLOWING INFORMATION FOR EACH LOAD OF
PEANUTS. INDICATE YOUR COMPANY NAME, BUYING POINT, AND REPORTING MONTH ON EACH PAGE.

FSA # 1007 NO.

FSA FARM ID
(ST/CT/FM/SMC)

ASSESSMENT COLLECTED

CERTIFICATION STATEMENT: I HEREBY CERTIFY that the information is true and correct to the best of my knowledge. The

remittance represents 1 percent of the price paid for all peanuts handled during this reporting period on which I was required to
pay the assessment. I also certify that I am authorized to sign this report. Any false statement or misrepresentation on this form
may result in a fine of not more than $10,000 or imprisonment for not more than 5 years, or both (18 U.S.C. 1001).
SIGNATURE

TITLE

FV-258-1 (06-07)

PRINTED OR TYPED NAME

DATE

See reverse for the Privacy Act, OMB, and nondiscrimination statements

Instructions
First handlers are required to file this report monthly. Complete Parts A, B and C. The
report and full remittance are due no later than 60 days after the last day of the month in
which the peanuts were marketed. A late fee of 15 percent is assessed on payments
received after the 60-day period. A handler operating in different regions must file a
separate report for each region. All reports are held in strict confidence.

Mail report and remittance to:

National Peanut Board
P.O. Box XXXXXX
City, State and Zip Code

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 0581-0189. The
time required to complete this information collection is estimated to average 45 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.

FV-258-1 (06-07)

(Reverse)