AVO-FHR Hass Avocado First Handler Report

Payment Due On or Before: OMB No. 0581-0093

HASS AVOCADO PROMOTION, RESEARCH, AND INFORMATION ORDER

(7 CFR 1219)

FIRST HANDLER REPORT

For the Month of .

MAIL TO: Hass Avocado Board, Department #xxxx, City, State, Zip Code

PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING

<<Contact Person>>

<<Business Name>>

<<Street Address>>

<<City>>, <<State>> <<ZIP>>

<<Telephone Number>>

Farm Tax ID # (TIN) or Employer Identification Number (EIN): ________________________

Enter total number of pounds of fresh HASS avocados handled ________________________

Enter total number of pounds of LAMB HASS handled ________________________

TOTAL POUNDS HANDLED ________________________

Deduct the number of pounds of fresh Hass avocados exported ________________________

Deduct the number of pounds of Certified Organic Hass avocados* ________________________

TOTAL POUNDS ON WHICH ASSESSMENT IS DUE ________________________

Assessment rate (x.x cents per pound) X $0.0xx

Total assessments due $ ________________________

I certify that the above information is true and correct to the best of my knowledge and the attached remittance represents x.x cents per pounds for all Hass avocados handled during this reporting period on which I was required to pay the assessment. I also certify that I am authorized to sign this report.

________________________________ ________________________________

NAME (PRINT) SIGNATURE

________________________________ ________________________________

TITLE DATE

The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, §1001 United States Code, which provides for the penalty of a fine of $10,000, imprisonment of not more than 5 years, or both.

To eliminate reports during a period of inactivity, complete the following statement:

I (we) do not wish to receive the blank assessment report(s) during the circled month(s) below since we will not pick any Hass or Lamb Hass avocados during these months:

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Signature: ________________________

* Handlers must have a “Certificate of Exemption” from each producer of organic and 100 percent Organic Hass Avocados operating under an Approved National Organic Program (7 CFR Part 205) a system from whom the handler received product.

READ INSTRUCTIONS ON OTHER SIDE

OMB No. 0581-0093

INSTRUCTIONS

First handlers are required to pay assessments and file this report monthly for each month in which they handle fresh Hass avocados. The original of the report must be received by the Hass Avocado Board, with full remittance, no later than the last business day of the month within 30 days after the end of the month in which the sale or non-sale transfer subject to assessments under the Hass Avocado Promotion, Research, and Information Order (7 CFR Part 1219). A late payment penalty and an interest charge will be applied to assessments that are delinquent. All reports are held in strict confidence by the staff of the Hass Avocado Board and the U.S. Department of Agriculture.

NOTE: The statements on the reverse 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 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.

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