RAS-AAC National Raspberry Council Application for Assessment Cr

Form Approved OMB 0581-NEW

NATIONAL RASPBERRY COUNCIL

APPLICATION FOR ASSESSMENT CREDITS

As stated in Section 1208.52(h) of the Processed Raspberry Promotion, Research and Information Order:

“Council may provide credits of assessments for those individuals who contribute to local, regional, or State organizations engaged in similar generic research, promotion, and information programs as partial fulfillment of assessment due to the Council subject to approval of the Secretary, for expenditure on generic research, promotion and information programs conducted within the United States.”

CERTIFICATION

(To Be Signed and Dated by Applicant)

I hereby certify that I have contributed to a local, regional, or State organization engaged in generic research, promotion, and information programs for the period of ____________. I therefore request a credit for assessments from the National Raspberry Council (Council) for assessments for the year 20XX.

Signature ____________________________________ Date: _________________

Please Print

Name of Applicant: _________________________________________________

Company Name (if applicable): _________________________________________

Street Address: ______________________________________________________

City: ________________________________ State: _________________________

Zip Code: ____________________ Telephone No. ________________________

Tax ID# or Business ID#: _________________________________

Amount contributed to local, regional, or State organization: $________________

Please send your completed Application for Assessment Credits to the National Raspberry Council at the following address (with documentation as required):

National Raspberry Council

Street

City, State Zip

RAS-AAC (03/09)

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 Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat. 1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number or Business Identification Number is mandatory, and will be used to determine affiliation or entity identification.

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 15

minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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.

RAS-AAC (03/09)