XMAS-AR Application for Refund

OMB #0581-0268

APPLICATION FOR REFUND

CHRISTMAS TREE 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.

INSTRUCTIONS:

1. This application must be postmarked within 30 days after the Secretary announces the results of the referendum.

2. Attach documentation or a copy thereof, or such evidence deemed satisfactory to the Board, with this application.

3. Applicant’s name must be the same as it appears on the bill of sale or other proof of sale.

4. Refund application must be signed by the person receiving the refund.

Applicant’s Name: ____________________________________________________________

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

Address: ___________________________________________________________________________________________

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

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

PROOF OF ASSESSMENT

Date(s) assessment(s) paid: ____________________________________________________________________

ENTER TOTAL NUMBER OF CHRISTMAS TREES CUT and SOLD on which assessments were paid: ___________________

AMOUNT OF ASSESSMENTS PAID: $___________________

ENTER TOTAL NUMBER OF CHRISTMAS TREES IMPORTED on which assessments were paid:______________________

AMOUNT OF ASSESSMENTS PAID ON IMPORTED CHRISTMAS TREES: $___________________ Country of Origin, Port of Entry No. and other information as requested: _____________________________________________

_____________________________________________________________________________________________________

TOTAL AMOUNT OF REFUND REQUESTED $_____________________

CERTIFICATION: I certify, under penalties provided by law, that: The applicant requesting this refund, paid the assessment for which a refund is sought. The information is correct and not false or fraudulent. A request has not previously been submitted, nor a refund received on the assessment paid above. I am authorized to sign this refund application on behalf of the applicant.

______________________________________________________ ______________________________________

NAME (PRINT) SIGNATURE

______________________________________________________ _________________________________

TITLE DATE

PENALTIES: You may, by law, be fined up to $10,000, imprisoned up to five years or both for knowingly or willfully making false statements within this document (18 U.S.C. Section 1001).

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Please Mail To: Christmas Tree Promotion Board

Street, City, State, Zip Code

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-AR (02-17) Destroy previous version.