POP-AAE Popcorn Application for Certificate of Exemption

OMB No. 0581-0093

APPLICATION FOR A CERTIFICATE OF EXEMPTION

POPCORN PROMOTION AND INFORMATION ORDER (7 CFR 1215)

YEAR BEING APPLIED FOR: 20XX

Please read the instructions at the bottom of this application before you complete it (please type or print)

This information is confidential and for the use by the Popcorn Board administrator only

and will not be disseminated to Board members and/or industry.

APPLICANT'S NAME	BUSINESS TELEPHONE NO., INCLUDE AREA CODE
BUSINESS FAX NO., INCLUDE AREA CODE	E-MAIL
BUSINESS NAME
BUSINESS ADDRESS	CITY STATE ZIP
TAX IDENTIFICATION NO. or EMPLOYER ID NO.	WEBSITE URL

I hereby CERTIFY that my annual total poundage of popcorn processed and distributed was 4 million pounds or less for the most recently completed calendar year. My annual poundage for January 1, through

December 31, 20XX was ___________________________Pounds. 1/

_________________________________________ _________________________________________

Name of Applicant (Print) Title

X_______________________________________ ________________________________________

Signature of Applicant Date

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

Return to:

The Popcorn Board

Address

City, State Zip

If your annual poundage of popcorn is 4 millions pounds or less, you are eligible to claim an exemption from assessments. The BOARD may 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 POPCORN BOARD. Any person desiring to renew an exemption must reapply annually to the POPCORN BOARD for another Certificate of Exemption. Please type or print this application.

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).

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 Popcorn Promotion, Research, and Consumer Information Act (7 U.S.C. 7481-7491). 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/hours 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 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.

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