Form XMAS-SI Christmas Tree Sales/Importer Report

OMB #0581-0268

CHRISTMAS TREE Promotion, RESEARCH and Information Order

SALES/IMPORTER REPORT

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.

Contact Person: _______________________________________________________________________________________

Company Name: ___________________________________________________ Tax ID# or Bus. ID#: ___________________

Address: ___________________________________________________________________________________________

City: ___________________ State: ____________ Zip Code: _____________ E-Mail: _________________________

Phone No.: ______________________ Fax No.:________________ Web-site: _____________________________

PERIOD COVERED BY THIS REPORT: DATE OF REPORT (Due to Board):

Due no later than February 15, 20XX, late fees and interest charges will be added to late payments

FOR ADDITIONAL SPACE, YOU MAY ATTACH YOUR OWN SEPARATE SHEETS. For questions about completing this report call (XXX) xxx-xxxx or email:

This section represents all assessable Christmas trees.

ENTER TOTAL NUMBER OF CHRISTMAS TREES CUT and SOLD (Exported to U.S.): ____________________

If address differs from above, please specify: __________________________________________________________

ENTER TOTAL NUMBER OF CHRISTMAS TREES IMPORTED: ____________________

Country of Origin/Port of Entry/Entry Number:_______________________________________________________

Assessment of $0.xxx per Christmas tree is due with this report by Feb. 15, 20XX X $0.xxx

TOTAL AMOUNT OF ASSESSMENTS DUE: $_____________________

CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.xxx per Christmas tree for all Christmas trees cut and sold or imported during this reporting period for which I am required to pay the assessments as the producer or importer. I will submit verification of the above upon request. I also certify that I am authorized to sign this report.

______________________________________________________ ______________________________________

NAME (PRINT) SIGNATURE

______________________________________________________ _________________________________

TITLE DATE

Due no later than February 15, 20xx Late fees and Interest Charges will be added to late payments

Please keep a copy of this form for your records/receipt along with a copy of your check.

Please Mail To: Christmas Tree Promotion Board

Street, City, State, Zip Code

Phone

Email

This report is required by law [7 U.S.C. 7416, 7 CFR Part 1214.52 and 7 CFR Part 1214.60]. Failure to report can result in a fine of not less than $1,200 or more than $12,000 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 0581-0268. 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.

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.

XMAS-SI (02/17) Destroy previous version.