Form HWL-AFR Application for Refund of Assessment Paid

OMB No. 0581-NEW

APPLICATION FOR REFUND OF ASSESSMENT PAID

HARDWOOD LUMBER AND HARDWOOD PLYWOOD PROMOTION,
RESEARCH AND INFORMATION ORDER
(7 CFR PART 1211)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. 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).

PLEASE READ THE INSTRUCTIONS OF APPLICATION

BEFORE COMPLETION (PLEASE TYPE OR PRINT)

Name of Applicant	Title	Business Telephone No. (include Area code)
Name of Business		Tax ID# or SS#
Business Address	City	State Zip

________________________________________ Fiscal Year ____________

(Certificate of Exemption No.)

Annual Sales of Hardwood Lumber	Annual Sales of Hardwood Lumber Products	Annual Sales of Hardwood Lumber Value-Added Products	Annual Sales of Hardwood Plywood	Amount of Assessments Collected

Total Amount of Assessments Collected to Be Reimbursed:

A reimbursement is hereby requested for the assessment collected on organic Hardwood Lumber or Hardwood Plywood, or paid by manufacturers on Hardwood Lumber or Hardwood Plywood that should have been exempted but was paid to the Hardwood Lumber and Hardwood Plywood Board on the above-described Hardwood Lumber and Hardwood Plywood. I certify that the above information provided in this application for reimbursement is true and correct to the best of my knowledge and I have not previously applied for a reimbursement on the above listed Hardwood Lumber. I further certify that I am authorized to file this application on behalf of the aforementioned business. 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).

INSTRUCTIONS

RECEIPTS OR COPIES THEREOF MUST BE ATTACHED TO THIS APPLICATION

Return to the: Hardwood Lumber and Hardwood Plywood Board

Street

City, State, Zip Code

Receipts or copies thereof, submitted with this application will not be returned. Type or Print this application. Attach additional pages if necessary.

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, 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-AFR (06/12)