MAN-AFR Mango Application for Reimbursement of Assessment

OMB No. 0581-0093

APPLICATION FOR REIMBURSEMENT OF ASSESSMENT
MANGO PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER
(7 CFR 1206)
PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE
BEFORE COMPLETION (PLEASE TYPE OR PRINT)
Name of Applicant (First handler or importer)
(print)

Business Telephone No. (include Area
code)

Title

Tax ID# or Employer ID#

Name of Business

Business Address

City

Name and address of Producers from
whom the First Handlers has received
Domestic Mangos or Port of Entry and
Entry No. for Imported Mangos

Date that assessments
were paid on Domestic
Mangos or Entry Date
for Imported Mangos

State

Domestic pounds
handled and exported or
pounds imported

Pounds of Domestic or
imported mangos on
which assessments
were paid

Zip

Amount of
Assessments
Collected

Total amount of assessment collected to be reimbursed: ____________________
Domestic mangos that are exported will not be assessed and Importers and First Handlers who receive a
certificate of exemption are eligible for reimbursement of any assessments paid. All requests for
reimbursement must be submitted to the National Mango Board (NMB) within 90 days of the last day of
the calendar year the mangos were imported or sold domestically.
Since I have been approved by the NMB as an exempt importer or first handler, a reimbursement is
hereby requested for the assessment collected by the U.S. Customs Service or paid by a first handler on
domestically produced mangos and paid to the National Mango Board on the above-described mangos. I
certify that the above information provided in this application for reimbursement is true and correct to the
best of my knowledge and I have not previously applied for a reimbursement on the above listed mangos.
I further certify that I am authorized to file this application on behalf of the aforementioned business. 1/
X_____________________________________________
Signature of Applicant

___________________________________
Date

1/ 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.

MAN-AFR (Rev. 03/17) Destroy previous versions.

INSTRUCTIONS
RECEIPTS OR COPIES THEREOF MUST BE ATTACHED TO THIS APPLICATION
Return to the National Mango Board
Street
City, State Zip Code
Receipts or copies thereof, submitted with this application will not be returned. Type or Print this application. Attach additional
pages if necessary.
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
importer 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 0581-0093. 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, 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.

MAN-AFR (Rev. 03/17) Destroy previous versions.