XMAS-RF Application for Reimbursement of Assessment

OMB No. 0581-0268

APPLICATION FOR REIMBURSEMENT OF ASSESSMENT

CHRISTMAS TREE PROMOTION BOARD

The information on this from is required to make a determination concerning an exempt importer’s eligibility for a refund of assessments collected by U.S. Customs Service during the applicable fiscal period in accordance with 7 CFR 1214.53(b).

PLEASE COMPLETE THE FOLLOWING:

Name of Applicant		Title
Name of Business		Tax ID# or SS#
Business Address	City	State Zip
Email Address		Business Telephone No. (include Area code)

_____________________________________ _____________________________________

(Importer No. or Broker No.) (Certificate of Exemption No.)

Port of Entry and Entry No. for Imported Christmas Trees	Entry Date of Imported Christmas Trees	Number of Christmas Trees on which assessments were paid	Amount of Assessment Collected
Total amount of assessment collected to be reimbursed:

CERTIFICATION STATEMENT

A reimbursement is hereby requested for the assessment collected by the U.S. Customs Service or paid by importers on Christmas trees that should have been exempted but was paid to the Christmas Tree Promotion Board on the above-described Christmas trees. 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 Christmas trees. I further certify that I am authorized to file this application on behalf of the aforementioned business.

____________________________ _____________________________ _____________

Signature Title Date

Please keep a copy for your records and submit this form and documentation to:

Christmas Tree Promotion Board Street Address City, State, Zip Phone (xxx) xxx-xxxx Email

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 the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat. 1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Business Identification Number is mandatory, and will be used to determine affiliation or entity identification.

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 0581-0268. 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.

XMAS-RF (02/20) Destroy previous version.

Exp. Date XX/XX/XXXX