LS-380 Application for Refund

REPRODUCE LOCALLY. Include form number and edition date on all reproductions			FORM APPROVED – OMB NO. 0581-0093
UNITED STATES DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SORGHUM PROMOTION, RESEARCH, AND INFORMATION PROGRAM A program of promotion, research, and information designed to strengthen, expand and develop new foreign and domestic markets for sorghum. APPLICATION FOR REFUND
Applicant acknowledges that this refund application is made pursuant to the Sorghum Promotion, Research, and Information Order. Note: 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 10 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. PENALTIES: You may, by law, be fined up to $10,000, imprisoned up to five years or both for knowingly or willfully making false statements within this document (18 U.S.C. Section 1001).
INSTRUCTIONS: This application must be postmarked within 60 days following the date that assessments were paid. But no later than the date the Secretary announces the results of the referendum Attach documentation or a copy thereof, or such evidence deemed satisfactory to the Board, with this application. Applicant’s name must be the same as it appears on the account of sale. Refund application must be signed by the person receiving the refund.
Applicant’s Name (first, last, middle)		MAIL THIS APPLICATION TO: U.S. Department of Agriculture c/o Sorghum Promotion, Research, and Information Board P.O. Box 23172 Washington, DC 20026-3172
Address
City, State, Zip Code
Telephone No. (include area code)
PROOF OF ASSESSMENT
a. Company collecting assessments
	Name
	Address
	City, State, Zip Code
b. Date(s) assessment paid
c. Weight or volume of Sorghum
d. Value of Sorghum
e. Total amount of refund requested $________________________
CERTIFICATION STATEMENT
I certify, under penalties provided by law, that: The applicant requesting this refund, paid the assessment for which a refund is sought. The information in this request is correct and not false or fraudulent. A request has not previously been submitted, nor a refund received on the assessment paid above. I am authorized to sign this refund application on behalf of the applicant.
SIGNATURE OF APPLICANT OF AUTHORIZED REPRESENTATIVE				DATE
LS-380 (06-08)