BLU-AAE Blueberry Application for Exemption from Assessment

Form Approved OMB 0581-0093

U.S. HIGHBUSH BLUEBERRY COUNCIL

APPLICATION FOR EXEMPTION FROM ASSESSMENT

As stated in Section 1218.53 of the Blueberry Promotion, Research and Information Order (Exemption Procedures):

“Any producer who produces less than 2,000 pounds of blueberries annually who desires to claim an exemption from assessments during a fiscal year as provided in Section 1218.42 shall apply to the U.S. Highbush Blueberry Council (USHBC), on a form provided by the USHBC, for a certificate of exemption. Such producer shall certify that the producer’s production of blueberries shall be less than 2,000 pounds for the fiscal year for which the exemption is claimed. Any importer who imports less than 2,000 pounds of fresh and processed blueberries annually who desires to claim an exemption from assessments during a fiscal year as provided in Section 1218.52 shall apply to the USHBC, on a form provided by the USHBC, for a certificate of exemption. Such importer shall certify that the importer’s importation of fresh and processed blueberries shall not exceed 2,000 pounds, for the fiscal year for which the exemption is claimed.”

CERTIFICATION

(To Be Signed and Dated by Applicant)

I hereby certify that my total level of blueberry production in 20XX, or the total fresh or processed blueberries I will import in 20XX, will be less than 2,000 pounds. I therefore request a certificate of exemption from the U.S. Highbush Blueberry Council (USHBC) assessments for the year 20XX.

Signature ____________________________________ Date: ________________

Please Print

Name of Applicant: _________________________________________________

Company Name (if applicable): _________________________________________

Street Address: ______________________________________________________

City: ________________________________ State: ________________________

Zip Code: __________________________

Please send your completed Certificate of Exemption Application to the U.S. Highbush Blueberry Council at the following address:

USHBC

Street

City, State Zip

BLU-AAE (09/07)

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 0581-0093. The time required to complete this information collection is estimated to average 15

minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

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BLU-AAE (09/07)