POP-FHR Popcorn First Handler (Quarterly Report)

Form Approved - OMB No. 0581-0093

QUARTERLY REPORT

POPCORN PROMOTION, RESEARCH AND CONSUMER INFORMATION

A program of promotion, research and consumer information NOTE: Information is required by 7 CFR 1215.

designed to strengthen the position of the popcorn industry Failure to report can result in a fine;

in the marketplace and to maintain and expand existing Information is held confidential

domestic and foreign markets and uses for popcorn. (7 CFR 1215).

REPORT AND REMITTANCE OF AMOUNT DUE FROM PROCESSORS PROCESSING AND MARKETING POPCORN IN THE U.S. (INCLUDING CANADA) OR FOR EXPORT

Name: Employer ID # or

Company: Tax ID#

Address (Include P.O. Box and Street):

City, State and ZIP:

Business and FAX Numbers (Include Area Code):

E-Mail Address:

The report and assessments are due by the last day of the month following the end of the collection period. The following is a report on popcorn marketed for the period commencing Month x, 20XX and ending Month xx, 20XX.

LIST ALL POUNDS OF POPCORN PROCESSED IN

THE U.S. AND SOLD IN THE U.S. (INCLUDING CANADA) OR EXPORTED: ^1/

(DO NOT INCLUDE SALES TO OTHER POPCORN PROCESSORS)

Month, 20XX Month, 20XX Month, 20XX

DOMESTIC (U.S. & Canada) DOMESTIC (U.S. & Canada) DOMESTIC (U.S. & Canada)

Subtotal ________________lbs. Subtotal ________________lbs. Subtotal ________________lbs.

EXPORTS EXPORTS EXPORTS

China/Hong Kong___________lbs. China/Hong Kong___________lbs. China/Hong Kong___________lbs.

Columbia/Costa Rica_________lbs. Columbia/Costa Rica ________lbs. Columbia/Costa Rica________lbs.

Mexico _________________lbs. Mexico _________________lbs. Mexico _________________lbs.

SE Asia*__________________lbs. SE Asia*__________________lbs. SE Asia*__________________lbs,

XXX_____________________lbs. XXX_____________________lbs. XXXX____________________lbs.

Other_____________________lbs. Other_____________________lbs. Other_____________________lbs.

Subtotal __________________lbs. Subtotal __________________lbs. Subtotal __________________lbs.

Total __________________lbs. Total __________________lbs. Total __________________lbs.

Grand Total (sum of three month totals)__________________________x $.xxx=$_____________________________.

This information is confidential and for the use by the Popcorn Board administrator only and will not be disseminated to Board members and/or industry.

Please send this report and a check in the total amount shown above to:

The Popcorn Board

Street

City, State Zip Code

CERTIFICATION STATEMENT

I declare, under the penalties provided by law, that this report has been examined by me and to the best of my knowledge and belief is a true, correct and complete report.

NAME/TITLE (Print or Type) SIGNATURE DATE

______________________________ ______________________________ ______________

-Over-

INSTRUCTIONS

Processors are required to file this report quarterly. The original of the report must be mailed to the Popcorn Board, with full remittance, by April 30, July 31, October 31, and January 31, for the fiscal year popcorn was processed. The Popcorn Board holds all such reports in strict confidence.

Region	List of Countries in Region
*SE Asia	Bangladesh, Brunei, Indonesia, Malaysia, Philippines, Singapore, Thailand, Vietnam.
XXX	XXX

Please mark "Final Report" if this is the last report of the year.

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.

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 Popcorn Promotion, Research, and Consumer Information Act (7 U.S.C. 7481-7491). 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 identity.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and 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 30 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.

POP-FHR (Rev. 03/17) Destroy previous editions.