MAN-FHR Mango- First Handler's Report

Mail to: National Mango Board

Street

City, State, Zip OMB No. 0581-0093

MANGO PROMOTION, RESEARCH, AND INFORMATION ORDER

(7 CFR 1206)

FIRST HANDLER'S REPORT

PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING

________________________________________________________________ ___________________________________________________________

(Name) (Telephone No.-include area code, FAX No., Email address)

_______________________________________________________________ ___________________________________________________________

(Name of Business/Company) (Tax ID # or Employer ID#)

_________________________________________________________________________________________________________________________________________

(Address) (City) (County) (State) (Zip)

REPORT OF MANGOS HANDLED DURING (MONTH) 20XX.

LIST BELOW THE NAME AND ADDRESS OF PRODUCERS FOR WHOM YOU HANDLED MANGOS.

NAME AND ADDRESS	PRODUCER FARM ID OR TAX ID NO.	DATE OF TRANSACTION	TOTAL POUNDS	ASSESSMENT PAID	DATE OF ASSESSMENT PAID

TOTAL 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 mangos 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.

READ INSTRUCTIONS ON OTHER SIDE

INSTRUCTIONS

First handlers are required to file this report monthly. The original of the report must be mailed to the National Mango Board, with full remittance, within 30 days after the end of the month in which the sale or non-sale transfer subject to assessments under part 1206. All reports are held in strict confidence by the National Mango Board.

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (5 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 importer 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 0581-0093. 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.

MAN-FHR (Expiration Date XX/XX/20XX) Page 1 of 2 See reverse for burden/non-discrimination statement