TM-33 FMPP Reviewer Declaration of Intent (for grant reviewers

OMB 0581-New

1. 

Farmers Market Promotion Program (FMPP)

Reviewer Declaration of Intent

The purpose of this form is to insure that as a peer reviewer for the _____ Farmers Market Promotion Program, that my participation does not constitute a conflict of interest in any manner. I certify the following statements to be true:

• I did not apply for an FMPP grant this fiscal year.

• I did not prepare an application for an FMPP grant this fiscal year.

• I am without any relationship to any organization applying for grant funds this fiscal year, i.e., 1) employed by, volunteer for, or serve as a board member or other committee/team member for an organization applying; or 2) subcontractor, financial, organizational or familial beneficiary from an organization applying.

___________________________________________

Print Name

__________________________________________

Signature

________________________________________________

Date

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-NEW  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 Oil the basis of race, color. national origin, age, disability, end where applicable sex, marital status, or 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 TOO). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250­9410 or call (SOD) 795·3272 (voice) or (202) 720-6382 (TOO). USDA is an equal opportunity provider and employer.

TM-33