MUS-AAE Mushroom Application for Certificate of Exemption

OMB No. 0581-0093

Application for a Certificate of Exemption

Mushroom Promotion, Research, and Consumer Information Order

Please Read the Instructions on the Reverse Side before Completion

_____________________________________________________________________________

(Name of Applicant) (Business Telephone No. With Area Code)

_____________________________________________________________________________

(Name of Business) (Business FAX Number)

_____________________________________________________________________________

(Physical Business Address) (City) (State) (Zip)

_____________________________________________________________________________

(Mailing Address if different) (City) (State) (Zip)

________________________________ OR __________________________________

(Tax I.D. No. Or Employer ID No.) (Importer No. Or Broker No.)

I hereby CERTIFY that my production or importation of mushrooms for fresh use will not exceed 500,000 pounds, on average, for the fiscal year in which this exemption is being claimed.

My estimated production or importation for the fiscal year for which this exemption is being claimed should be ___________ pounds.¹

My actual production or importation in the preceding fiscal year was ____________ pounds.¹

My "on average" production or importation should be ____________ pounds.¹

__________________________________________ _____________________________

Name of Applicant (Print) Title

____________________________________________ _____________________________

Signature of Applicant Date

1/ Any false statement or misrepresentation 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).

MUS-AAE (rev. 08/10) Destroy previous editions.

Certification of Exemption Application Instructions

The term "on average" shall be calculated by averaging an applicant's estimated production or importation for the fiscal year for which an exemption is being claimed with the applicant's production or importation in the preceding fiscal year. For example, if the applicant has estimated production for the fiscal year for which an exemption is claimed to be 450,000 pounds and the applicant's actual production in the preceding fiscal year was 500,000 pounds. The total for these two years is 950,000 pounds making the applicant's "on average" production 475,000 pounds. Such a volume of production will make the applicant eligible to claim an exemption from assessments.

The Mushroom Council may require persons receiving an exemption from assessments to provide reports on the disposition of their mushrooms. All persons shall be liable for paying assessments should their "on average" production or importation exceed 500,000 pounds. Any person who desires to renew their exemption from assessments shall reapply to the Mushroom Council for another certificate of exemption. Please type or print this application.

Return completed form to: MUSHROOM COUNCIL

Street

City, State Zip

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 Mushroom Promotion, Research, and Consumer Information Act of 1990 (7 U.S.C. 6101-6112). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) is mandatory, and will be used to determine affiliation or entity identity.

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.

MUS-AAE (rev. 08/10) Destroy previous editions.