Form XMAS-AE Application for Exemption from Assessment

Form Approved OMB 0581-0268 CHRISTMAS TREE PROMOTION BOARD

APPLICATION FOR EXEMPTION FROM ASSESSMENT

As stated in Section 1214.53 of the Christmas Tree Promotion, Research and Information Order (Exemption from assessments):

Any producer who cuts and sells or importer who imports less than 500 Christmas trees in a fiscal year who desires to claim an exemption from assessments as provided in Section 1214.52 shall apply to the Christmas Tree Promotion Board (Board), on a form provided by the Board, for a certificate of exemption. Such producer or importer shall certify that the producer cut and sold or importer imported less than 500 Christmas trees for the fiscal year for which the exemption is claimed.

CERTIFICATION

(To Be Signed and Dated by Applicant, Deadline to file application is February 15, 20XX)

I hereby certify that I cut and sold in the United States or imported to the United States less than 500 Christmas trees in 20XX. I therefore request a certificate of exemption from the Christmas Tree Promotion Board (Board).

Signature Date:

Please Print

Name of Applicant:

Company Name :

Street Address:

City: State:

Zip Code:

Telephone No.

Email Address

Tax ID# or Business ID#:

Number of Trees Sold 20XX Acres Planted to Christmas Trees

Please keep a copy of this form for your records and send your completed and signed Certificate of Exemption Application to the Christmas Tree Promotion Board at the following address:

Christmas Tree Promotion Board

Address

City, State Zip Code

Phone Number

Email

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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 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 (TIN) or Business Identification Number is mandatory, and will be used to determine affiliation or entity identification.

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 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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.

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