DESIGNATED HANDLER’S REPORT FOR POTATO RESEARCH AND PROMOTION ACT

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CHRISTMAS TREE Promotion, RESEARCH and Information Order
SALES/IMPORTER REPORT








Contact Person: ____________________________________________________________
Company Name: ___________________________________________________ Tax ID# or Bus. ID#: ___________________
Address:  ___________________________________________________________________________________________
City: ___________________   State: ____________     Zip Code: _____________    E-Mail: _________________________
Phone No.: ______________________         Fax No.:________________      Web-site: _____________________________
 PERIOD COVERED BY THIS REPORT:                                               DATE OF REPORT (Due to Board):
FOR ADDITIONAL SPACE, YOU MAY ATTACH YOUR OWN SEPARATE SHEETS.  For questions about completing this report call (XXX) xxx-xxxx
This section represents all assessable Christmas trees.
ENTER TOTAL NUMBER OF CHRISTMAS TREES CUT and SOLD:                                                  ____________________
If address differs from above, please specify: __________________________________________________________
ENTER TOTAL NUMBER OF CHRISTMAS TREES IMPORTED:                                                        ____________________
    Country of Origin/Port of Entry/Entry Number:______________ _________________________________________

          Assessment of $0.xxx per Christmas tree is due with this report                                                                 X   $0.xxx

TOTAL AMOUNT OF ASSESSMENTS DUE:                                                                                      $_____________________

CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.xxx per Christmas tree for all Christmas trees cut and sold or imported during this reporting period for which I am required to pay the assessments as the producer or importer.  I will submit verification of the above upon request.  I also certify that I am authorized to sign this report.

     ______________________________________________________            ______________________________________
            NAME (PRINT)								SIGNATURE
    
    ______________________________________________________  		_________________________________
TITLE									DATE


Please Mail To:  Christmas Tree Promotion Board
Street, City, State, Zip Code


This report is required by law [7 U.S.C. 7416, 7 CFR Part 1214.52 and 7 CFR Part 1214.60].  Failure to report can result in a fine of not less than $1,200 or more than $12,000 for each such violation.  Each such violation shall be deemed a separate violation.  The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, Section 1001 United States Code, which provides for the penalty of a fine of $10,000 or imprisonment of not more than five years, or both.


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 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.