SC-265 Application for Certification of Peanut Organization

FORM APPROVED - OMB NO. 0581-0093

REPRODUCE LOCALLY. Include form number and date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

NATIONAL PEANUT BOARD
APPLICATI ON FOR CERTIFICATION OF PEANUT ORGANIZATION

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 058 10093. 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, 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.

INSTRUCTIONS: Please print or type in all applicable spaces and sign your name. The following information is to
be submitted by each peanut organization that applies for certification to submit nominations for National Peanut
Board membership to the Secretary of Agriculture and/or to submit requests for funding to the National Peanut
Board. Attach separate sheets of paper as necessary (make reference to appropriate question number(s).
1a. NAME OF APPLICANT ( Organization )

1b. MAILING ADDRESS (Number, Street, City, State, ZIP Code)

1c. TELEPHONE NO. (Include area code)

1d. FAX TELEPHONE NO.

1e. E-MAIL ADDRESS

2a. NAME OF CHAIRPERSON OR OTHER CHIEF ELECTED OFFICIAL

2b. TITLE
2c. TELEPHONE NO. (Include area code)

2d. FAX TELEPHONE NO.

2e. E-MAIL ADDRESS

3a. NAME OF CHIEF STAFF OFFICER
3b. TITLE
3c. TELEPHONE NO. (Include area code)

3d. FAX TELEPHONE NO.

3e. E-MAIL ADDRESS
__________________________________________________________________________________________________________________________________
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4. PLEASE CHECK THE REASON(S} FOR THIS APPLICATION: (Mark an "X" on appropriate line)

NOMINATIONS_____

5a. IS THIS PEANUT PROMOTION ENTITY AUTHORIZED BY STATE STATUTE? (Mark an "X" on appropriate line)

YES

FUNDS _____
NO

5b. IF "YES", ATTACH A COPY OF THE RELEVANT STATUTE AND PROVIDE THE FOLLOWING:
NAME OF STATE STATUTE

DATE OF CREATION OF ENTITY

6a. DOES THIS APPLICANT CURRENTLY RECEIVE ASSESSMENTS OR CONTRIBUTIONS FROM PRODUCERS? (Mark an "X "On appropriate l i n e )
YES

NO ____

6b. IF "YES," DESCRIBE THE ASSESSMENT RATE OR THE BASIS FOR CONTRIBUTIONS (rate per ton, percent of price, etc.)

6c. DESCRIBE THE MANNER IN WHICH THE APPLICANT ASSESSES (Attach separate sheet of paper):

1. Peanuts grown in applicant’s State, but sold in another State; and
2. Peanuts grown in a State other than the applicant’s State, but sold in the applicant’s State.
6d. ARE ANY PEANUTS EXEMPT FROM ASSESSMENT? (Mark an "X " on appropriate line)

YES

NO _____

6e. IF "YES", EXPLAIN BELOW OR ON SEPARATE SHEET OF PAPER:

7. DOES THIS APPLICANT CURRENTLY CONDUCT ANY OF THE FOLLOWING IN-STATE AND/OR ON A NATIONAL BASIS'
(Mark an "X " in appropriate box(es)

IN-STATE

a.

Promotion

b.

Research

c.

Consumer Information

d.

Industry Information

NATIONAL

IF 7a THROUGH 7d DO NOT APPLY, SKIP TO QUESTION 7f

7e. ARE ANY OF THE PROGRAMS REFERRED TO IN QUESTIONS 7a THROUGH 7d INTENDED TO STRENGTHEN THE PEANUT INDUSTRY'S
POSITION IN THE MARKET PLACE? (Mark and “X” on the appropriate line)
YES

NO_ _ _ _

7f. IF THE APPLICANT HAS NOT YET COLLECTED ASSESSMENTS FROM PRODUCERS, OR HAS NOT YET CONDUCTED A PROGRAM OF
PEANUT PROMOTION, RESEARCH, CONSUMER INFORMATION, AND/OR I NDUSTRY INFORMATION, DESCRIBE IN DETAIL THE
CURRENT PLANS, NOT DISCUSSED ELSEWHERE IN THIS APPLICATION, TO IMPLEMENT SUCH A PROGRAM AND THE PROJECTED DATE
OF IMPLEMENTATION OF SUCH A PROGRAM (If not enough space below, attach separate sheets of paper for description).

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8a DESCRIBE ON SPEARATE SHEET OF PAPER, THE MANNER IN WHICH ASSESSMENTS ARE (OR WILL BE) COLLECTED
FROM PRODUCERS IN YOUR STATE. INCLUDE THE FOLLOWING INFORMATION IN YOUR ANSWER:
1. Identification by job or title (i.e., Federal-State inspectors, markets, buyers, etc.), those persons or entities responsible for
collecting assessments;
2. The procedures for accounting and remittance to the applicant by such collection persons;
3. Whether assessments are authorized by State law or established by organization action;
4. The time that such assessments are collected and the time period within which the collecting persons must remit the
assessments to the applicant (or State agency on behalf of the applicant);
5. Whether the applicant will have any employees exclusively (or primarily) responsible for administering the collection as
assessments; and
6. Any other information necessary to provide a thorough understanding of the manner in which this applicant collects
assessments.
8b DESCRIBE ON SEPARATE SHEET OF PAPER, THE PROCEDURE(S) UTILIZED BY THE APPLICANT TO ENSURE THAT
ASSESSMENT DUE FROM PRODUCERS ARE PAID. INCLUDE THE FOLLOWING INFORMATION IN YOUR ANSWER:
1. Description of any compliance program established by the applicant (or a State agency on behalf of the applicant);
2. If assessments are not paid, the steps to be taken to secure payment; and
3. Any other information necessary to provide a thorough understanding of this entity’s efforts to ensure that assessments are
paid.
9a. DOES THIS APPLICANT CERTIFY THAT IT WILL FURNISH TO THE NATIONAL PEANUT BOARD AN ANNUAL FINANCIAL REPORT BY A CERTIFIED
PUBLIC ACCOUNTANT OF ALL FUNDS RECEIVED FROM THE NATIONAL PEANUT BOARD?
YES _____ NO _____
9b. DOESTHIS APPLICANT CERTIFY THAT IT WILL FURNISH TO THE NATIONAL BOARD AN ANNUAL MARKETING PLAN?
YES ______ NO _______

9c DOES THIS APPLICANT CERTIFY THAT IT WILL FURNISH TO THE NATIONAL BOARD ANY ADDITIONAL INFORMATION AND REPORTS THE BOARD
OR SECRETARY OF AGRICULTURE MAY REQUEST/
YES ______ NO _______

TOTAL BUDGET

$

EXPENDITURES ON CONSUMER INFORMATION

$

EXPENDITURES ON INDUSTRY INFORMATION

$

EXPENDITURES FOR THE PURPOSE OF
INFLUENCING LEGISLATION OR GOVERNMANET
ACTION OR POLICY

$

ADMINISTRATIVE EXPENSES $
EXPENDITURES ON PROMOTION

EXPENDITURES ON RESEARCH

$
$

10b. DOES THIS APPLICANT AGREE THAT IT WILL NOT USE ANY FUNDS COLLECTED PURSUANT TO THE ACT AND THE ORDER FOR THE
PURPOSE OF INFLUENCING ANY LEGISLATION OR GOVERNMENTAL ACTION OR POLICY?
YES ______ NO _____

10c. DOES THIS APPLICANT AGREE THAT IT WILL NOT FINANCE, WITH FUNDS RECEIVED PURSUANT TO THE ACT AND THE ORDER, PLANS
OR PROJECTS WHICH ARE FALSE OR MISLEADING OR DISPARAGE ANOTHER AGRICULTURAL COMMODITY OR CREATE A CONFLICT OF
INTEREST?
YES ______ NO ______
___________________________________________________________________________________________________________________________

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11. LIST THE NAMES, ADDRESSES, AND TITLES OF ELECTED AND STAFF OFFICERS AND ANY ORGANIZATIONAL TIES OF THE OFFICIALS
OF THIS APPLICANT.
NAME

TITLE

ORGANIZATION
REPRESENTED

ADDRESS

12. ENCLOSE A COPY OF APPLICANT’S MOST RECENT ANNUAL BUDGET, MARKETING PLAN, ANNUAL REPORT, AND FINANCIAL AUDIT.

13. PLEASE ATTACH ANY ADDITIONAL REMARK S WHICH MAY BE RELEVANT OR NECESSARY FOR THE SECRETARY TO DETERMINE
WHETHER THE APPLICANT SHOULD BE CERTIFIED.
CERTIFICATION STATEMENT

I HEREBY CERTIFY that the information provided in response to the above items is true, complete, and correct to the
best of my knowledge. I further state that I am authorized to submit this document on behalf of the applicant and to
make the representations and certifications contained herein. The Secretary of the United States Department of
Agriculture and the employees or agents of the National Peanut Board may examine our hooks, records, files, and
facilities to verify any of the information submitted and may procure such other information as may be required to
determine the applicant's eligibility for qualification.
SIGNATURE

TITLE

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PRINTED OR TYPED NAME

DATE

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