RAS-AFR Raspberry--Application for Reimbursement of Assessment

OMB No. 0581-0093

APPLICATION FOR REIMBURSEMENT OF ASSESSMENT
PROCESSED RASPBERRY PROMOTION, RESEARCH
AND INFORMATION ORDER
(7 CFR PART 1208)
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 AT BOTTOM OF APPLICATION
BEFORE COMPLETION (PLEASE TYPE OR PRINT)

Name of Applicant

Title

Name of Business

Business Address

_____________________________________
(Importer No. or Broker No.)

Business Telephone No. (include Area code)

Tax ID# or Business ID#

City

State

Zip

_____________________________________
(Certificate of Exemption No.)

Name & Address of Producers from whom First Handler has
received Domestic Raspberries for Processing OR
Port of Entry and Entry No. for Imported Processed
Raspberries

Date that assessments
were paid on Domestic
Raspberries for Processing
OR

Pounds of Domestic
or Imported Processed
Raspberries which
assessments were paid

Amount of
Assessment Collected

Entry Date of Imported
Processed Raspberries

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 processed raspberries that should
have been exempted but was paid to the National Processed Raspberry Council on the above-described processed raspberries. 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 processed raspberries. I further certify that I am authorized to file this application on behalf of the aforementioned
business. 1/

_________________________________________
Name of Applicant (Print)

____________________________________________
Title

X_________________________________________
Signature of Applicant

____________________________________________
Date

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.

RAS-AFR (Rev. 03/17) Destroy previous edition.

INSTRUCTIONS
RECEIPTS OR COPIES THEREOF MUST BE ATTACHED TO THIS APPLICATION
Return to the National Processed Raspberry Council
Address
City, State zip

Receipts or copies thereof, submitted with this application will not be returned. Type or Print this application. Attach additional pages
if necessary.

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.

RAS-AFR (Rev. 03/17) Destroy previous edition.