Form PPQ 651R PPQ 651R Application for Plum Pox Compensation

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 0579-0159. The time required to complete this information collection is estimated to average .5 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.			OMB Approved 0579-0159 EXP XX/XXXX
United States Department of Agriculture Animal and Plant Health Inspection Service Plant Protection and Quarantine Application for Plum Pox Compensation
1. Name of Applicant:	2. Address of Applicant (Include ZIP Code):		3. Tax ID NUMBER:
4. Location of the Affected Orchard Block(s) or Nursery:
5. Date Destruction Order or Emergency Action Notification (EAN) Issued:		6. Date(s) Actual destruction oF Orchard or Nursery Stock Occurred:
NOTE: When submitting this application, you must provide copies of the destruction order or EAN and its accompanying inventory describing the trees or nursery stock subject to the destruction order or EAN.
7. FOR ORCHARDS: AGE OF ORCHARD AND EXACT ACREAGE DESTROYED (to 1/10th of an acre). IF the orchard contained trees of different ages, list the exact acreage of each age population in the orchard.
8. For Nurseries: Number (by age and species) of Trees in the nursery that were subject to the emergency action notification.
I certify that all statements and entries I have made on this document are true and accurate to the best of my knowledge and belief. I understand that many intentional false statement or misrepresentation made on this document is a violation of law and punishable by a fine of not more than $10,000, or imprisonment of not more than 5 years, or both (18 U.S.C. 1001).
Applicant’s Signature:				Date:

PPQ Form 651-R

AUG 2009