AMS-23 State and Tribal Hemp Producer Report

REPRODUCE LOCALLY. STATE AND TRIBAL HEMP PRODUCER REPORT. OMB No. 0581-0318

U NITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

USDA DOMESTIC HEMP PRODUCTION PROGRAM

STATE AND TRIBAL HEMP PRODUCER REPORT

Reporting Period: _________________ to _________________

State or Tribe Name: ________________ Date Submitted: __________

The USDA Domestic Hemp Production Program requires states and tribes with approved plans to submit contact information and the status of the license for each producer under their plan.

Instructions:

This information must be submitted to the U.S. Department of Agriculture (USDA) on the 1^st day of each month. If this date falls on a holiday or weekend, the reports are due the next business day. Each monthly report is for new producers and changes to existing producer information only.

Producers: Report all required information for each producer licensed under the Plan.

Changes to Producer Information: Report any changes to reported information for producers that were included in previous reports. These changes include but are not limited to; a change of license status, an address change, a change in the key participant of a business or an updated phone number.

This report should be submitted to USDA using a digital format compatible with USDA’s information sharing systems, whenever possible. If this is not possible, please submit report to:

By Mail: USDA/AMS/Specialty Crops Program Hemp Branch 470 L’Enfant Plaza S.W. Post Office Box 23192 Washington, D.C. 20026

Or via Email at: [email protected]

Or via Fax at: (202) 720-8938

The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the 7 CFR Part 990 Domestic Hemp Program (Program).  The purpose of collecting this information is for USDA to administer the Program and the information provided on this form will be used to monitor Program participants. Failure to provide the information requested on this form may result in ineligibility to participate in the Program.

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 OMB 0581-NEW. The time required to complete this information collection is estimated to average 20 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.

List all producers and business entities in the space below:

Individual or Entity Name	Name of Producer(s)/Key Participant(s)	License Identifier or other Authorization Identifier	New Producer? (Yes, No)	Business Address of Producer(s) or Entity	Telephone #	Email Address (if available)	Status of License (active, revoked, suspended)

(Use additional pages if needed)

Employees Submitting Criminal History Record Report by Entity:

Individual or Entity Name	Name of Employee	Title of Employee	Employee Email Address (if available)

(Use additional pages if needed)

Document any changes to existing producer information in the space below:

	Individual or Entity Name	Name of Licensee(s)	License Identifier or other Authorization Identifier	Business Address of Producer(s)	Telephone #	Email Address (if available)	Status of License (active, revoked, suspended)
Current Information
New Information
Current Information
New Information
Current Information
New Information
Current Information
New Information

(Use additional pages if needed)

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.

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