HON-AFR Honey-Application for Reimbursement of Assessment

OMB No. 0581-0093

APPLICATION FOR REIMBURSEMENT OF ASSESSMENT
HONEY PACKERS AND IMPORTERS RESEARCH, PROMOTION,
CONSUMER EDUCATION AND INDUSTRY INFORMATION ORDER
(7 CFR PART 1212)
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 THE BACK OF APPLICATION
BEFORE COMPLETION (PLEASE TYPE OR PRINT)

Name of Applicant

Title

Business Telephone No. (include Area code)

E-mail address

Fax number (include Area code)

Name of Business

Tax ID# or SS#

Business Address
_____________________________________
(Importer No. or Broker No.)

City

State

Zip

_____________________________________
(Certificate of Exemption No.)

Name & Address of Producers from whom First Handler has
received Domestic Honey & Honey Products OR
Port of Entry and Entry No. for Imported Honey or Honey
Products

Date that assessments
were paid on Domestic
Honey & Honey Products
OR
Entry Date of Imported
Honey & Honey Products

Pounds of Domestic
or Imported Honey
and Honey products
which assessments
were paid

Amount of
Assessment Collected

Total amount of assessment collected to be reimbursed:

A reimbursement is hereby requested for the assessment collected by the U.S. Customs Service or paid by first handlers on
honey and honey products that should have been exempted but was paid to the National Honey Board on the above-described
honey and honey products. I certify that the above information provided in this application for reimbursement is true and
correct to the best of my knowledge and I have not previously applied for a reimbursement on the above listed honey and
honey products. I further certify that I am authorized to file this application on behalf of the aforementioned business. 1/
________________________________________________________________
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
HON-AFR (Rev. 03/17) Destroy previous editions.

OMB No. 0581-0093

INSTRUCTIONS
ATTACH APPROPRIATE DOCUMENTATION TO SUPPORT YOUR APPLICATIONS. REQUESTS FOR
REIMBURSEMENT MUST BE SUBMITTED TO THE BOARD WITHIN 90 DAYS OF THE LAST DAY OF THE
CALENDAR YEAR THE HONEY OR HONEY PRODUCTS WERE HANDLED OR IMPORTED.

Return to the:
National Honey Board
Street Address
City, State, Zip Code
Documentation submitted with this application will not be returned. Type or Print this application. Attach additional
pages if necessary.

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-AFR (03/17) Destroy previous editions.