Application for A Certificate of Exemption

OMB No. 0581-0093

APPLICATION FOR A CERTIFICATE OF EXEMPTION

HONEY PACKERS AND IMPORTERS RESEARCH, PROMOTION, CONSUMER

EDUCATION AND INDUSTRY INFORMATION ORDER

(7 CFR PART 1212)

YEAR BEING APPLIED FOR: 20XX

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat. 1032 (7 U.S.C. 7411-7425).

PLEASE READ THE INSTRUCTIONS AT BOTTOM OF THIS APPLICATION

PLEASE TYPE OR PRINT

APPLICANT'S NAME	BUSINESS TELEPHONE NO., INCLUDE AREA CODE
BUSINESS NAME
BUSINESS ADDRESS	CITY STATE ZIP
TAX or BUSINESS IDENTIFICATION NO. or SOCIAL SECURITY NO.

I hereby CERTIFY that:

__ I am a first handler and I handled pounds of honey and honey products during the year 20xx.

__ I am an importer and I imported pounds of honey and honey products during the year 20xx.

____________________________________________________ __________________________________

Name of Applicant (Print) Title

___________________________________________________ ___________________________________

Signature of Applicant Date

*************** INSTRUCTIONS ***************

Return to:

Honey Packers and Importers Board

Street

City, State, Zip Code

If you are a first handler or importer of honey and honey products, and you handled or imported less than 250,000 pounds during the calendar year for which the exemption is claimed, you are eligible to claim an exemption from assessments. The Honey Packers and Importers Board will require persons applying for an exemption from assessments to provide substantiating information supporting their exemption status. All persons are liable for paying assessments, except those who have a Certificate of Exemption issued by the Honey Packers and Importers Board and must be renewed annually by the Honey Packers and Importers Board.

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).

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, 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.

(rev. 08/10) (Expires XX/XX/XXXX)