SWL-AFR Softwood Lumber--Application for Refund of Assessment

OMB No. 0581-0093

APPLICATION FOR REFUND OF ASSESSMENT PAID
SOFTWOOD LUMBER RESEARCH, PROMOTION, CONSUMER EDUCATION AND
INDUSTRY INFORMATION ORDER
(7 CFR PART 1217)
The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) 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).

PLEASE READ THE INSTRUCTIONS OF APPLICATION
BEFORE COMPLETION (PLEASE TYPE OR PRINT)

Name of Applicant

Title

Business Telephone No. (include Area code)

Name of Business

Business Address

Tax ID# or SS#

City

_____________________________________
(Importer No. or Broker No.)
Port of Entry and Entry No. for Imported Softwood Lumber

State

Zip

_____________________________________
(Certificate of Exemption No.)
Entry Date of Imported Softwood
Lumber

Number of Softwood
Lumber on which
assessments were paid

Amount of Assessment
Collected

Total amount of assessment collected to be reimbursed:

A reimbursement is hereby requested for the assessment collected by the U.S. Customs Service on organic Softwood
Lumber or paid by importers on Softwood Lumber that should have been exempted but was paid to the Softwood
Lumber Board on the above-described Softwood Lumber. 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 Softwood Lumber. I further certify that I am authorized to file this application on
behalf of the aforementioned business. 1/
_______________________________________________________

___________________________________________________________

Name of Applicant (Print)

Title

_________________________________________
Signature of Applicant

____________________________________________
Date

1/ The making of any false statement or misrepresentation on this form, knowing it to be false, is a violation of Title 18, Section 1001 United States Code, which
provides for in the penalty of a fine of not more than $10,000, or imprisonment of not more than 5 years, or both.

SWL-AFR (rev. 03/17) Destroy previous edition.

INSTRUCTIONS
RECEIPTS OR COPIES THEREOF MUST BE ATTACHED TO THIS APPLICATION
Return to the: Softwood Lumber 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: 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 05810093. 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.

SWL-AFR (rev. 03/17) Destroy previous edition.