Form XMAS-SD Domestic Sales Report

OMB #0581-0268

CHRISTMAS TREE PROMOTION, RESEARCH, AND INFORMATION ORDER DOMESTIC SALES REPORT
The information on this form is required for the payment of assessments to the Christmas Tree Promotion Board (CTPB) on domestic Christmas trees that are cut and sold (7 CFR 1214.52).
Contact Person:		Tax ID# or Bus. ID#:
Company Name:
Address:
City/State/Zip Code:
Phone #:		Fax #:
Email:		Website:
DOMESTIC CHRISTMAS TREES Christmas tree means any tree of the coniferous species, that is severed or cut from its roots and marketed as a Christmas tree for holiday use (7 CFR 1214.3). This report is due no later than February 15, 20xx. Late fees and interest charges will be added to late payments. Producer shall maintain any books and records necessary to verify information on this report. Such books and records must be made available during normal business hours for inspection by the CTPB. All information will be kept confidential by the CTPB staff. Such information shall not be available to CTPB members, producers, or importers.
YEAR COVERED BY THIS REPORT:		20XX
U.S. STATE(S) WHERE CHRISTMAS TREES WERE CUT: (You may attach your own sheet)		TOTAL NUMBER OF CHRISTMAS TREES CUT AND SOLD:
TOTAL CHRISTMAS TREES FOR ALL U.S. STATES:
Multiply Total Christmas Trees by Assessment Rate		$0.XXX
TOTAL AMOUNT OF ASSESSMENTS DUE BY FEBRUARY 15, 20XX:		$

CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.xx per Christmas tree for all Christmas trees cut and sold during this reporting period for which I am required to pay the assessments as the producer. I will submit verification of the above upon request. I also certify that I am authorized to sign this report.
Print Name:		Title:
Signature:		Date:
Mail this form and check to: Please keep a copy for your records along with a copy of your check.		Christmas Tree Promotion Board Address City, State, Zip Phone Email

This report is required by law [7 U.S.C. 7416, 7 CFR Part 1214.52 and 7 CFR Part 1214.60]. Failure to report can result in a fine of not less than $1,558 or more than $15,582 for each such violation. Each such violation shall be deemed a separate violation. 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.

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 30 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-SD (02/20) Destroy previous version.

Exp. Date XX/XX/XXXX