HON-AAE HONEY--Application for A Certificate of Exemption

OMB No. 0581-0093
APPLICATION FOR A CERTIFICATE OF EXEMPTION
HONEY PACKERS AND IMPORTERS RESEARCH, PROMOTION, CONSUMER
EDUCATION AND INDUSTRY INFORMATION ORDER
(7 CFR 1212)
YEAR BEING APPLIED FOR: _____
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 from the applicable commodity legislation for research and
promotion programs. 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.

PLEASE READ THE INSTRUCTIONS ON BACK OF THIS APPLICATION
PLEASE TYPE OR PRINT
Applicant’s Name

Business Telephone No. Including Area Code

Business Name

Business Address

City, State, Zip

Tax ID or Business Identification No.

Email Address

I hereby CERTIFY that:
handling ____________________ pounds of honey and honey
 I am a first handler and I anticipate
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products during the year 20xx.

 I am an importer and 1I anticipate importing ____________________ pounds of honey and honey product
during the year 20xx.

If you are a first handler or an importer and handle over 250,000 pounds of honey and honey products in a year, in which
you have applied for and been granted an exemption, you must pay the applicable assessment to the National Honey
Board, to be postmarked on or before XX/XX/XXXX of the subsequent year.

Name of Applicant (Print)

Title

Signature of Applicant

Date

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

OMB No. 0581-0093
************ INSTRUCTIONS

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Return to:
National Honey Board
Street Address
City, State, Zip

If you are a first handler or importer of honey and honey products, and you handled or imported less than 250,000 pounds
during the calendar year for which the exemption is claimed, you are eligible to claim an exemption from assessments.
The National Honey Board will 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 National Honey Board and must be renewed annually by the National Honey
Board.
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.

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 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.

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