POP-FHR Popcorn First Handler (Quarterly Report)

Form Approved - OMB No. 0581-0093

QUARTERLY REPORT

POPCORN PROMOTION, RESEARCH AND CONSUMER INFORMATION

A program of promotion, research and consumer information NOTE: Information is required by 7 CFR 1215.

designed to strengthen the position of the popcorn industry Failure to report can result in a fine;

in the marketplace and to maintain and expand existing Information is held confidential

domestic and foreign markets and uses for popcorn. (7 CFR 1215).

REPORT AND REMITTANCE OF AMOUNT DUE FROM PROCESSORS PROCESSING AND MARKETING POPCORN IN THE U.S. (INCLUDING CANADA) OR FOR EXPORT

Name: Employer ID # or

Company: Tax ID#

Address (Include P.O. Box and Street):

City, State and ZIP:

Business and FAX Numbers (Include Area Code):

E-Mail Address:

The report and assessments are due by the last day of the month following the end of the collection period. The following is a report on popcorn marketed for the period commencing Month x, 20XX and ending

Month xx, 20XX.

LIST ALL POUNDS OF POPCORN PROCESSED IN

THE U.S. AND SOLD IN THE U.S. (INCLUDING CANADA) OR EXPORTED: ^1/

(DO NOT INCLUDE SALES TO OTHER POPCORN PROCESSORS)

Month, 20XX Month, 20XX Month, 20XX

DOMESTIC (U.S. & Canada) DOMESTIC (U.S. & Canada) DOMESTIC (U.S. & Canada)

Subtotal ________________lbs. Subtotal ________________lbs. Subtotal ________________lbs.

EXPORTS EXPORTS EXPORTS

China____________________lbs. China____________________lbs. China____________________lbs.

Mexico _________________lbs. Mexico _________________lbs. Mexico _________________lbs.

SE Asia*__________________lbs. SE Asia*__________________lbs. SE Asia*__________________lbs,

XXX_____________________lbs. XXX_____________________lbs. XXXX____________________lbs.

Other_____________________lbs. Other_____________________lbs. Other_____________________lbs.

Subtotal __________________lbs. Subtotal __________________lbs. Subtotal __________________lbs.

Total __________________lbs. Total __________________lbs. Total __________________lbs.

Grand Total (sum of three month totals)__________________________x $.xxx=$_____________________________.

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.

Please send this report and a check in the total amount shown above to:

The Popcorn Board

Street

City, State Zip Code

CERTIFICATION STATEMENT

I declare, under the penalties provided by law, that this report has been examined by me and to the best of my knowledge and belief is a true, correct and complete report.

NAME/TITLE (Print or Type) SIGNATURE DATE

______________________________ ______________________________ ______________

-Over-

INSTRUCTIONS

Processors are required to file this report quarterly. The original of the report must be mailed to the Popcorn Board, with full remittance, by April 30, July 31, October 31, and January 31, for the fiscal year popcorn was processed. The Popcorn Board holds all such reports in strict confidence.

Region	List of Countries in Region
*SE Asia	Bangladesh, Brunei, Indonesia, Malaysia, Philippines, Singapore, Thailand, Vietnam.
XXX	XXX

Please mark "Final Report" if this is the last report of the year.

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 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 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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.

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).

POP-FHR (rev. 12/13) Destroy previous editions.