Form HWL-SRP Quarterly Sales Report

OMB No. 0581-NEW

Quarterly Sales Report

Hardwood Lumber and Hardwood Plywood Promotion, Research and Information Order

(7 CFR 1211)

Quarterly Report/Remittance of Assessments

Name of Business: ____________________________________________ Contact Person:___________________________________

Business Address: ___________________________________________________ Tax I.D. No. ________________________________

City, State, Zip:___________________________________________________ Telephone Number:____________________________

E-mail: ____________________________________________________ Web Site: _________________________________________

Part A: Report for the _________ Quarter 20XX (please specify) (Quarters are as follows: 1=Jan., Feb., Mar.; 2 = Apr., May, June; 3 = Jul, Aug., Sept.; 4 = Oct., Nov., Dec.)

Part B: Fill-out below as applicable.

Assessment Owed

1. Hardwood Lumber:

$____________

X

$X.00

÷

$X,000

=$_____________

(sales)

2. Hardwood Lumber Products:

($___________

X

$X.00)

—

($___________

X

$X.00)

÷

$X,000

=$_____________

(sales)

(Green kiln dried lumber purchases)

3. Hardwood Lumber Value-Added Products:

($___________

X

$X.00)

+

($___________

X

$X.00)

—

($___________

X

$X.00)

÷

$X,000

=$_____________

(sales)

(Green kiln dried lumber sales)

(Green kiln dried lumber purchases)

4. Hardwood Plywood:

$____________

X

$X.00

÷

$X,000

=$_____________

(sales)

Total Assessment:

$______________

I certify under the penalties provided by law, that this report is a true, correct, and complete report. I also certify that I am authorized to sign this report.¹

Print Name: ____________________________________________ Title: ___________________________________________________

Signature: _______________________________________________________ Date: __________________________________________

¹ Any false statement or misrepresentation my 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).

Please Mail to: Hardwood Lumber and Hardwood Plywood Promotion, Research and Information Board

Street

City, State, Zip Code

INSTRUCTIONS:

Manufacturers are required to pay assessments and file this report no later than the thirtieth calendar day of the month following the end of the quarter in which the hardwood lumber, hardwood lumber products, value-added, or hardwood plywood was marketed. The fiscal year runs from January through December. There are four quarters in each fiscal year. Quarter 1 covers January, February and March. Quarter 2 covers April, May, and June. Quarter 3 coves July, August, and September. Quarter 4 covers October, November, and December. Assessments for hardwood lumber marketed during Quarter 1 are due by April 30; for Quarter 2 by July 30; for Quarter 3 by October 30, and for Quarter 4 by January 30. All reports are held in strict confidence by the staff of the Board and the U.S. Department of Agriculture (USDA).

This report is required by law [7 U.S.C. 7416, 7 CFR Part 1211.52 and 7 CFR Part 1211.70]. Failure to report can result in a fine of not less than $1,000 or more than $10,000 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.

HWL-SRP (06/12)