POP-AAE Popcorn Application for Certificate of Exemption

OMB No. 0581-0093

APPLICATION FOR A CERTIFICATE OF EXEMPTION

POPCORN PROMOTION AND INFORMATION ORDER (7 CFR 1215)

YEAR BEING APPLIED FOR: 20XX

Please read the instructions at the bottom of this application before you complete it (please type or print)

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.

APPLICANT'S NAME	BUSINESS TELEPHONE NO., INCLUDE AREA CODE
BUSINESS FAX NO., INCLUDE AREA CODE	E-MAIL
BUSINESS NAME
BUSINESS ADDRESS	CITY STATE ZIP
TAX IDENTIFICATION NO.	WEBSITE URL

I hereby CERTIFY that my annual total poundage of popcorn processed and distributed was 4 million pounds or less for the most recently completed calendar year. My annual poundage for January 1, through

December 31, 20XX was ___________________________Pounds. 1/

_________________________________________ _________________________________________

Name of Applicant (Print) Title

X________________________________________ ________________________________________

Signature of Applicant Date

*************** INSTRUCTIONS ***************

Return to:

The Popcorn Board

Address

City, State Zip

If your annual poundage of popcorn is 4 millions pounds or less, you are eligible to claim an exemption from assessments. The BOARD may require persons applying for an exemption from assessments to provide substantiating information supporting their exemption status. All persons are liable for paying assessments, except those who have a Certificate of Exemption issued by the POPCORN BOARD. Any person desiring to renew an exemption must re-apply annually to the POPCORN BOARD for another Certificate of Exemption. Please type or print this application.

1/ Any false statement or misrepresentation may result in a fine of not more than $10,000, or imprisonment for not more than 5 years, or both (18 U.S.C. 1001).

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 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.

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