Pima Cotton Agriculture Trust Fund

For Pima Agriculture Cotton Trust OMB No.: 0551 – 0044

Expires 12/31/2017

Affidavit of Shirting Manufacturer to Claim Payment from

The Pima Agriculture Cotton Trust Fund in 2015

Filed pursuant to section 12314 of the Agricultural Act of 2014

(P. L. 113-79)

(1) The undersigned, _______________________________________, certifies and affirms that I am _____________ of __________________________, an officer of a manufacturer that cuts and sews men’s and boys’ woven cotton shirts in the United States.

(2) I certify and affirm that __________________________________________ has a manufacturing facility that cuts and sews men’s and boys’ woven cotton shirts located at ______________________________________, and has manufactured (cut and sewn such apparel items) at such address during calendar year 2013 and during the period January 1, 2014 through today using imported cotton fabrics described in paragraph (3) below.

(3) I certify and affirm that ________________________ purchased imported woven cotton shirting fabric of 80s or higher count and 2-ply in warp during calendar year 2013 with a value (excluding duty, shipping, and related costs) of $_____________________ .

(4) I certify and affirm that _______________________ maintains invoices along with other supporting documentation (such as price lists and other technical descriptions of the fabric qualities) showing the dollar value of such fabric purchased, the date of purchase, and evidencing the fabric as woven cotton fabric of 80s or higher count and 2-ply in warp. For purposes of this affidavit, the date of purchase is the invoice date, and the dollar value is determined excluding duty, shipping, and related costs.

(5) I certify and affirm that the fabric referenced herein was suitable for use in the manufacturing of men’s and boy’s cotton shirts.

I certify and affirm that to the best of my knowledge and belief all information contained in this claim and affidavit is complete and correct and no false claims, statements, or representations have been made.

_________________ _____________________________________

Date Signature

_____________________________________

Title

_____________________________________

Company Name

______________________________________

______________________________________

Address

( State of ____________________________

( County/City of _______________________

__________________________subscribed and sworn to before me this affidavit for a claim for payment from the Pima Agriculture Cotton Trust Fund this ____ day of __________, 2015.

Signature of Notary Public

__________________________________

My Commission expires _____________

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