MUS-FHR Mushroom First Handler Report

FIRST HANDLER REPORT OMB No. 0581-0093

MUSHROOM, PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER

MONTHLY REPORT/REMITTANCE OF ASSESSMENTS

Please Read the Instructions on the Reverse Side

Before Completion

_________________________________________________________________________________

(Name of Authorized Individual) (Business Telephone No., Include Area Code)

_________________________________________________________________________________

(Name of Business) (Tax I.D No. or Employer ID No.)

_________________________________________________________________________________

(Business Address) (City) (County) (State) (Zip)

PART A: REPORT OF MUSHROOMS MARKETED FOR FRESH USE DURING THE MONTH OF ____________@$______per pound.

PART B: PROVIDE THE FOLLOWING INFORMATION ON ALL PERSONS WHO PRODUCED MUSHROOMS FROM WHOM YOU MARKETED SUCH MUSHROOMS FOR FRESH USE. IF APPLICABLE, INCLUDE SUCH INFORMATION FROM YOUR OWN PRODUCTION.

NAME AND ADDRESS OF PRODUCER		TAX I.D. NO. OR EIN	TOTAL LBS MARKETED (SOLD)		TOTAL DOLLAR VALUE OF LBS MARKETED (SOLD)		CERTIFICATE OF EXEMPTION NO. (IF APPLICABLE)	ASSESSABLE FRESH LBS MARKETED (SOLD)		ASSESSMENT DUE
**Attach additional pages if necessary						Subtotal (this page)
						Subtotal (other pages)**
						Total Assessments Due
						Less Total Prepaid Credit
						Remaining Prepaid Credit

I certify under the penalties provided by law, that this report is a true, correct,

and complete report. I also certify that I am authorized to sign this report. ¹

______________________________________________________________________________________________________

Name of Individual (Print) Title

____________________________________________________________________________________________

Signature of Individual Date

MUS-FHR (09/07) - over -

INSTRUCTIONS

First handlers must collect and remit federally mandated assessments on mushrooms marketed for fresh use to the Mushroom Council. This report must be mailed to the Mushroom Council with full remittance. A check, draft, or money order made payable to the MUSHROOM COUNCIL for the "TOTAL MANDATORY ASSESSMENT DUE" must be sent with this report.

This report and assessment payment must be postmarked or received by the Mushroom Council within 15 days (due date) after the end of the month such mushrooms were marketed. Any report not postmarked within 15 days after the end of the month assessments are due will be assessed a one-time late payment charge of 10 percent. In addition to the late payment charge, a 1‑½ percent per month (18 percent per annum) interest charge will be added to any account delinquent beyond the last day of the second month following the month the mushrooms involved were marketed and will continue monthly until the outstanding balance is paid to the Mushroom Council. All reports are held in strict confidence by the Mushroom Council.

Mail this report with payment in full to:

MUSHROOM COUNCIL

File No. XXXXXXX

City, State Zip

Please mark "Final Report" if this is the last report of the Mushroom Council's fiscal year.

¹ Any false statement or misrepresentation 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).

_____________________________________________________________________________________________________

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is the Mushroom Promotion, Research, and Consumer Information Act of 1990 (7 U.S.C. 6101-6112). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) is mandatory, and will be used to determine affiliation or entity identity.

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 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.

MUS-FHR (09/07)