No Form Number Cotton--Application for Reimbursement of Assessment on I

Print Form

Application for Reimbursement
of Assessment on Imported Cotton and
Cotton Content of Imported Products

OMB No. 0581-0093

Cotton Board
5050 Poplar Avenue
Suite 1900
Memphis, TN 38157

Reimbursement No.
For CB Office purposes only

Phone: (901) 683-2500
Fax: (901) 685-1401
Importer of Record Name and Address:

Reimbursement Mailing Address:
Name

Name

Address

Address
City

State

Zip

City

State

Zip

Customs Importer Identification No.

Telephone
Contact Person

Check Appropriate Category:

U.S. Produced Cotton

No Cotton Content

Extra Long Staple Cotton

Corrections

Description of Merchandise*
10 Digit HTS Classification
of the Imported Product

Continued on page 2

Net Weight
In Kilograms

$ Amount of
Cotton Fee Paid

Date Fee
Was Paid

I have attached a separate spreadsheet with this information

Customs District of Entry

Exporting Country

Country of Origin

Total Reimbursement Requested $
Certification: I declare that the information provided in this application is true and correct to the best of my knowledge. If any information changes
after submission of this application, I will immediately notify the Cotton Board.
Please print and sign below.
Printed Name

Signature

Date

*Attach a copy of the U.S. Customs and Border Protection form 7501 Entry Summary and Commercial invoices or other such documentation in english indicating the origin
of the production or type of the cotton fiber used to produce the imported product.
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 - 0093. The time required to complete this information
collection is estimated to average 30 minutes/hours 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

Description of Merchandise - Continued*
10 Digit HTS Classification
of the Imported Product

Net Weight
In Kilograms

$ Amount of
Cotton Fee Paid

Date Fee
Was Paid

Please enter the total $ Amount of Cotton Fee Paid on page 1.
*Attach a copy of the U.S. Customs and Border Protection form 7501 Entry Summary and Commercial invoices or other such documentation in english indicating the origin
of the production or type of the cotton fiber used to produce the imported product.
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 0581-0093. The time required to complete this information collection
is estimated to average 30 minutes/hours 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