MUS-AAE Mushroom Application for Certificate of Exemption

OMB No. 0581-0093

Application for a Certificate of Exemption

Mushroom Promotion, Research, and Consumer Information Order

Please Read the Instructions on the Reverse Side before Completion

_____________________________________________________________________________

(Name of Applicant) (Business Telephone No. With Area Code)

_____________________________________________________________________________

(Name of Business) (Business FAX Number)

_____________________________________________________________________________

(Physical Business Address) (City) (State) (Zip)

_____________________________________________________________________________

(Mailing Address if different) (City) (State) (Zip)

________________________________ OR __________________________________

(Tax I.D. No. Or Employer ID No.) (Importer No. Or Broker No.)

I hereby CERTIFY that my production or importation of mushrooms for fresh use will not exceed 500,000 pounds, on average, for the calendar year in which this exemption is being claimed.

• My actual production or importation in the preceding calendar year was _________pounds.¹

• My estimated production or importation for the calendar year for which this exemption is being claimed should be ___________ pounds.¹

Thereforre, my "on average" production or importation should be ____________ pounds.^{1, 2}

__________________________________________ _____________________________

Name of Applicant (Print) Title

____________________________________________ _____________________________

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.

2/ The term “on average” shall be calculated by adding the producer’s or importer’s pounds from the preceding calendar year with the pounds estimated for the calendar year the exemption is being claimed and dividing by two. For example, if a producer’s or importer’s pounds from the preceding year was 450,000 pounds and the pounds estimated for the calendar year the exemption is being claimed is 500,000 pounds, then the total “on average” pounds would be 475,000.

MUS-AAE (rev. 03/17) Destroy previous editions.

Certification of Exemption Application Instructions

The term "on average" shall be calculated by averaging an applicant's estimated production or importation for the fiscal year for which an exemption is being claimed with the applicant's production or importation in the preceding fiscal year. For example, if the applicant has estimated production for the fiscal year for which an exemption is claimed to be 450,000 pounds and the applicant's actual production in the preceding fiscal year was 500,000 pounds. The total for these two years is 950,000 pounds making the applicant's "on average" production 475,000 pounds. Such a volume of production will make the applicant eligible to claim an exemption from assessments.

The Mushroom Council may require persons receiving an exemption from assessments to provide reports on the disposition of their mushrooms. All persons shall be liable for paying assessments on total production or importation should their "on average" production or importation exceed 500,000 pounds. Any person who desires to renew their exemption from assessments shall reapply to the Mushroom Council for another certificate of exemption. Please type or print this application.

Return completed form to: MUSHROOM COUNCIL

Street

City, State Zip

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 Mushroom Promotion, Research, and Consumer Information Act of 1990 (7 U.S.C. 6101-6112). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) 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 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.

MUS-AAE (rev. 03/17)Destroy previous editions.