RAS-AAC Raspberry--Application for Assessment Credits

Form Approved OMB 0581-0093
NATIONAL PROCESSED RASPBERRY COUNCIL
APPLICATION FOR ASSESSMENT CREDITS
As stated in Section 1208.52(h) of the Processed Raspberry Promotion,
Research and Information Order:
“Council may provide credits of assessments for those individuals who contribute to local, regional, or State
organizations engaged in similar generic research, promotion, and information programs as partial fulfillment of
assessment due to the Council subject to approval of the Secretary, for expenditure on generic research,
promotion and information programs conducted within the United States.”

CERTIFICATION
(To Be Signed and Dated by Applicant)

I hereby certify that I have contributed to a local, regional, or State organization engaged
in generic research, promotion, and information programs for the period of ____________.
I therefore request a credit for assessments from the National Processed Raspberry Council
(Council) for assessments for the year 20XX.
Signature ____________________________________ Date: _________________
Please Print
Name of Applicant:

_________________________________________________

Company Name (if applicable): _________________________________________
Street Address: ______________________________________________________
City: ________________________________ State: _________________________
Zip Code: ____________________ Telephone No. ________________________
Tax ID# or Business ID#: _________________________________
Amount contributed to local, regional, or State organization: $________________
Please send your completed Application for Assessment Credits to the National Processed
Raspberry Council at the following address (with documentation as required):
National Processed Raspberry Council
Address
City, State zip

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

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 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.
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-AAC (Rev. 03/17) Destroy previous edition.