ORG-RAE Entity Registration & Application for Exemption from Ass

OMB No. 0581-NEW

ORGANIC RESEARCH AND PROMOTION ORDER

(7 CFR 1255)

ENTITY REGISTRATION STATEMENT AND APPLICATION FOR EXEMPTION FROM ASSESSMENT FORM

The information on this form is required to make a determination concerning a person’s eligibility for exemption from assessments under research and promotion programs. NOTE: This form is NOT for applications for exemption for dual-covered commodities.

Contact Person:______________________________________________________________

Company Name:_________________________ Tax ID#/Importer ID#:_________________

Address:____________________________________________________________________

City: _______________________State: _________________Zip Code: _________________

E-mail: ____________________________Web site: _________________________________

Telephone Number: ______________________Fax No.______________________________

NOTE: A copy of this entity’s current organic production and/or handling certificate provided by a USDA-accredited certifying agent must be attached. Importers must attach a copy of producer and/or handler certificates for the products imported. If applicable, the equivalency agreement for the eligible product as established under the USDA National Organic Program (NOP) should also be noted.

Amount

Total Gross sales in Organic Products (Gross Organic Revenue):

Producers and Handlers: Does Gross Organic Revenue total $250,000 or more for the previous calendar year? Importers: Does Annual Transaction Value in organic products total $250,000 or more for the previous calendar year? If so, you will be required to remit an assessment.

$

If your Gross Organic Revenue or Transaction Value is less than $250,000 and you would like to apply for exemption from assessments, please check the following box and complete the remainder of this form. [ ] I intend to participate in this program as a voluntarily assessed entity.

If your Gross Organic Revenue or Transaction Value is less than $250,000 but you would like to register to voluntarily participate in the program please check the following box and complete the remainder of this form. [ ] I intend to participate in this program as a voluntarily assessed entity.

Insert Any Deductible Amounts Paid to Qualified State Commodity Boards:

$

Total:

$

Description

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Total

Operating Receipts and Cash Inflows (Gross Organic Revenue)

CSA

$

Farmers Markets

$

Retail Outlets

$

Other:

Total Cash inflows

$

List all certified organic products produced, handled, and imported in the previous calendar year:

Certification Statement

I certify that the above information is true and correct to the best of my knowledge. I also certify that I am authorized to sign this report.

Print Name and Title of Person Completing this Report

Signature Date

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).

Please Mail this form to our LOCK BOX ADDRESS:

Organic Research and Promotion Board

Street

City, State Zip code

Or e-mail this report to:

Please contact: xxxx

Continue to next page for anti-discrimination statement.

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 from the applicable commodity legislation for research and promotion programs. Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or importer identification number 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 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-NEW. The time required to complete this information collection is estimated to average 53 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: 1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; 2) fax: (202) 690-7442; or 3)email: [email protected].

USDA is an equal opportunity provider, employer, and lender.

ORG-RAE