AMS-15 Organic Exemption Request Form 5-2017

Organic Exemption Request Form
[Insert board/council name here]

OMB No. 0581-0093

The information on this form is required to make a determination concerning a person’s eligibility for exemption from
assessments under research and promotion programs.

Type of Operation: Insert appropriate program operations. See supplemental list. (Boards that assess only
one type of operation may omit this section.)

Please complete the following:
Applicant’s First and Last Name:
Company
name:
Street
address:

Phone:
Fax:

City/State/Zip
code:

E-mail:
Importer
ID #

Tax ID #

In order to be exempt, the above-named company must meet all of the following (please check):
Operates under an approved organic system plan authorized under the USDA-AMS organic
regulations (7 CFR Part 205) and maintains a valid organic certificate issued by an AMS
accredited certifying agent.

(Produces/handles/imports/manufactures/feeds/exports/processes) products eligible to be labeled
“organic” or “100% organic” under the USDA organic regulations.

Is subject to assessments under the research and promotion program for which this exemption
is requested.
A copy of this company’s organic farm or organic handling operation certificate and
addendum provided by a USDA-accredited certifying agent under the OFPA must be
attached. Importers should attach a copy of a certificate or equivalency agreement for the
eligible product as established under NOP. (Boards that do not assess importers may



delete the second sentence.)
Certification Statement

I hereby certify that my annual (basis of assessment, including but not limited to production,
processing, importation) is an estimated total ___________ (lbs., tons, value, etc), with _____________
(lbs., tons, value, etc.)“organic” and/or “100% organic” and ___________(lbs., tons, value, etc.) nonorganic. 1

____________________________
Signature

_____________________________
Title

_____________

Date

1/ Any false statement or misrepresentation may result in a fine of not more than $10,000, or imprisonment for not more than 5 years or both
(18 U.S.C. 1001).

[Insert Board/Council/other entity]
Please return this form to:

AMS-15 (Rev. 4/17) Destroy previous editions.

______________________________
______________________________
See reverse for burden/non-discrimination statement

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.

AMS-15 Supplemental List
_________________________________________________________________________________________
Type of Operation Selections:
_________________________________________________________________________________________



Producer





Handler

Seed Stock Producer




First Handler
Feeder



Processor



Importer

 Domestic Manufacturer



Exporter