RAS-FHR Raspberry--First Handler/Importer Report

OMB No. 0581-0093

FIRST HANDLER’S/IMPORTER’S REPORT FOR PROCESSED RASPBERRY
PROMOTION, RESEARCH, AND INFORMATION ORDER

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.

Name: ____________________________________________________________

Company Name: ______________________________________ Tax ID# or Business ID#: ____________

Address: _______________________________________________________________________________

City: ___________________ State: ____________ Zip Code: _____________

E-Mail: _________________________ Web site: ______________________________

Phone No.: ______________________ Fax No.:__________________

PERIOD COVERED BY THIS REPORT:

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 processed raspberries.

1.) LIST POUNDS OF PROCESSED RASPBERRIES OF YOUR OWN PRODUCTION: ____________________

2.) LIST POUNDS OF PROCESSED RASPBERRIES PURCHASED FROM PRODUCERS:

List the name and address and other pertinent information of each producer along with the corresponding pounds purchased
from each producer.

__________________________________________________________________ __________________

__________________________________________________________________ _________________

3.) LIST POUNDS OF PROCESSED RASPBERRIES IMPORTED:

List the total of each Harmonized Tariff Code along with the corresponding pounds imported.

__________________________________________________________________ _________________

__________________________________________________________________ _________________

__________________________________________________________________ _________________

TOTAL ALL POUNDS FROM ABOVE. _______________________

4.) DEDUCT THE NUMBER OF POUNDS OF CERTIFIED ORGANIC PROCESSED RASPBERRIES*: ____________________

TOTAL POUNDS ON WHICH ASSESSMENT IS DUE: _______________________

Assessment rate $0.xx per pound. x 0.xx

ASSESSMENTS DUE: ___________________________

5.) DEDUCT ASSESSMENT CREDITS: _____________________________

TOTAL ASSESSMENTS DUE __________________________

CERTIFICATION AND SIGNATURE

I certify that the information is true and correct to the best of my knowledge and the attached payment represents $0.xx per pound on all processed raspberries handled/imported during this reporting period for which I am required to pay the assessments as the first handler/importer. I also certify that I am authorized to sign this report.

________________________________________________________________________

Print Name and Title of Person Completing this Report

Signature Date

Please Mail To: Raspberry Board

Street

City, State, Zip

This report is required by law [7 U.S.C. 7416, 7 CFR Part 1212.52 and 7 CFR Part 1212.70]. Failure to report can result in a fine of not less than $1,000 or more than $10,000 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 0581-0093. 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, 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.

RAS-FHR (12/13) Destroy previous editions.