F/H Form H Hazelnuts Statement of Expense

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823

Fax: (503) 678-6825

STATEMENT OF EXPENSE

If you have no expense, please so state, sign and return this form.

NAME ______________________________________________________________________________

ADDRESS ___________________________________________________________________________

Expenses incurred attending _____________________________________________________________

Miles ___________ @ _________ $ ________________________

Other _______________________ $ ________________________

Expenses incurred attending _____________________________________________________________

Miles ___________ @ _________ $ ________________________

Other _______________________ $ ________________________

Expenses incurred attending _____________________________________________________________

Miles ___________ @ _________ $ ________________________

Other _______________________ $ ________________________

Miscellaneous expenses (please itemize below) ______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

TOTAL $ ________________________

_______________________________________

Signature

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 0581-0178. The time required to complete this information collection is estimated to average 3 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.

F/H Form H (Rev. 01/2014) Destroy previous editions.