Form XMAS-SI Christmas Tree Sales/Importer Report

OMB #0581-0268

CHRISTMAS TREE Promotion, RESEARCH and Information Order

SALES/IMPORTER REPORT

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). 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.

Contact Person: ____________________________________________________________

Company Name: ___________________________________________________ Tax ID# or Bus. ID#: ___________________

Address: ___________________________________________________________________________________________

City: ___________________ State: ____________ Zip Code: _____________ E-Mail: _________________________

Phone No.: ______________________ Fax No.:________________ Web-site: _____________________________

PERIOD COVERED BY THIS REPORT: DATE OF REPORT (Due to Board):

FOR ADDITIONAL SPACE, YOU MAY ATTACH YOUR OWN SEPARATE SHEETS. For questions about completing this report call (XXX) xxx-xxxx

This section represents all assessable Christmas trees.

ENTER TOTAL NUMBER OF CHRISTMAS TREES CUT and SOLD: ____________________

If address differs from above, please specify: __________________________________________________________

ENTER TOTAL NUMBER OF CHRISTMAS TREES IMPORTED: ____________________

Country of Origin/Port of Entry/Entry Number:_______________________________________________________

Assessment of $0.xxx per Christmas tree is due with this report X $0.xxx

TOTAL AMOUNT OF ASSESSMENTS DUE: $_____________________

CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.xxx per Christmas tree for all Christmas trees cut and sold or imported during this reporting period for which I am required to pay the assessments as the producer or importer. I will submit verification of the above upon request. I also certify that I am authorized to sign this report.

______________________________________________________ ______________________________________

NAME (PRINT) SIGNATURE

______________________________________________________ _________________________________

TITLE DATE

Please Mail To: Christmas Tree Promotion Board

Street, City, State, Zip Code

This report is required by law [7 U.S.C. 7416, 7 CFR Part 1214.52 and 7 CFR Part 1214.60]. Failure to report can result in a fine of not less than $1,200 or more than $12,000 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 0581-0268. 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.

XMAS-SI (02-14)