MUS-FHR Mushroom First Handler Report

First Handler Report
Mushroom Promotion, Research, and Consumer Information Order
Monthly Report/Remittance of Assessments
							OMB No. 0581-0093
Name of Business:				Phone Number:
Business Address:				Tax I.D. No:
City, State, Zip:				Preparer Name:
Part A: Report of Mushrooms Marketed for Fresh Use During the Month of:				20XX @	x.xxx	per pound
Part B: Provide the following information on all mushrooms you purchased, produced, and received.
Name & Address	Tax I.D. or EIN No.	Exemption Number or "Paid" if Previously Assessed	Total Pounds Purchased, Produced, & Received (4)	Total Pounds Exempt & Previously Assessed (5)	Total Pounds Marketed as Processed (6)	Total Pounds Marketed as Fresh = Column 4 minus Column 5 minus Column 6	Total Pounds Marketed as Fresh X $0.xxx = Total Assessment Due
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		Subtotal this page	$-	$-	$-	$-
		Subtotal other pages
		Total this month	$-	$-	$-	$-	$-
		Previous months Total Y-T-D amount
		Total Y-T-D	$-	$-	$-	$-	$-
					Total Assessments Due		$-
					Less Prepaid Credit
Part C: Total Dollar Value of Pounds Marketed as Fresh:		$			Remaining Balance Due		$-
I certify under the penalties provided by law, that this report is a true, and correct, and complete report. I also certify that I am authorized to sign this report.1
Print Name: ________________________________________________			Title:
Signature: ____________________________________________________			Date:
1 Any false statement or misrepresentation may result in a fine of not more than $10,000, imprisonment for not more than 5 years, or both (18 U.S.C. §1001).						Page ________ of _________
MUS-FHR (Expiration Date XX/XX/20XX)		Page 1 of 4
First Handler Report - Continuation Sheet
							OMB No. 0581-0093
Name of Business:				Month Reporting:
Part B continued: Provide the following information on all mushrooms you purchased, produced, and received.
Name & Address	Tax I.D. or EIN No.	Exemption Number or "Paid" if Previously Assessed	Total Pounds Purchased, Produced, & Received (4)	Total Pounds Exempt & Previously Assessed (5)	Total Pounds Marketed as Processed (6)	Total Pounds Marketed as Fresh = Column 4 minus Column 5 minus Column 6	Total Pounds Marketed as Fresh X $0.xxx = Total Assessment Due
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		Subtotal this page	$-	$-	$-	$-
I certify under the penalties provided by law, that this report is a true, and correct, and complete report. I also certify that I am authorized to sign this report.1
Print Name: ________________________________________________			Title:
Signature: ____________________________________________________			Date:
1 Any false statement or misrepresentation may result in a fine of not more than $10,000, imprisonment for not more than 5 years, or both (18 U.S.C. §1001).						Page ________ of _________
MUS-FHR (Expiration Date XX/XX/20XX)		Page 2 of 3
First Handler Report Instructions
Mushroom Promotion, Research, and Consumer Information Order
First handlers (Order 1209.6) must collect and remit federally mandated assessments on mushrooms marketed for fresh use to the Mushroom Council (Order 1209.51). This report must be mailed to the Mushroom Council with full remittance. A check, draft, or money order made payable to the MUSHROOM COUNCIL for the "TOTAL ASSESSMENT DUE" must be sent with this report. Mail this report with payment in full to: MUSHROOM COUNCIL
				Street
				City, State, ZIP
1. Name of Business: Enter Legal name of business
2. Business Address: Enter physical address of business
3. City, State, Zip: Enter physical city, State, & zip of business
4. Phone number: Enter the phone number of person preparing this report
5. Tax I.D. No: Enter company Tax I.D. number
6. Preparer Name: Enter name of person preparing report
Part A: Report of Mushrooms Marketed for Fresh use during the Month of: Enter reporting month
Part B:
1. Name & Address: Enter name & address for mushroom producer or supplier*
	*All sources of mushrooms MUST be listed even if the assessment was paid by another handler. Sources can include brokers, canners, wholesalers, other handlers, sideways sales, or growers.
2. Tax I.D. or EIN No.: Enter Tax I.D or EIN number for the producer or supplier listed in column 1
3. Exemption Number or "Paid" if previously assessed:
a.	Enter Council supplied exemption number if purchased from an exempt producer OR
b.	If pounds were purchased from another handler and the pounds were previously assessed write "paid" in this space
4. Total Pounds Purchased, Produced & Received: Enter all pounds acquired from name entered in first column
5. Total Pounds Exempt & Previously Assessed Pounds:
a.	Enter the number of pounds that are exempt from assessment (must have a Council supplied Exemption Certificate) OR
b.	Enter the number of pounds that were purchased from another handler and were previously assessed & paid
6. Total Pounds Marketed as Processed: Enter the number of pounds that were NOT sold as fresh such as marinated, canned, frozen, cooked, blanched, dried, packaged in brine. (Order 1209.11)
7. Total Pounds Marketed as Fresh subject to Assessment:			Take the Total pounds purchased, produced, & received (Column 4)
		Minus -	Exempt & previously assessed pounds (Column 5)
		Minus -	Total pounds marketed as processed (Column 6)
		=	Total Pounds Marketed as Fresh Subject to Assessment (Column 7)
8. Total Assessment Due: Take the Total Pounds Marketed as Fresh Subject to Assessment (Column 7) and multiply by the current per pound assessment rate
MUS-FHR (Expiration Date XX/XX/20XX)		Page 3 of 4
First Handler Report Instructions (continued)
9. Subtotal this page: Subtotal each column on each page
10. Subtotal other pages: Write in the subtotal from all additional pages for each column. If no additional pages, leave this blank.
11. Total this month: Add the figures for "Subtotal this page" and "Subtotal other pages" together. If no other pages then enter the number entered in "Subtotal this page" box.
12. Previous months total Y-T-D amount: Take the figures from the "Total Y-T-D" boxes from the previous month and write them here
13. Total Y-T-D: This figure should be a continuous total for the calendar year. Add the figures for "Total this month" and "Previous months total Y-T-D amount" to get the "Total Y-T-D" figure
14. Total Assessments Due: This figure is the total of all assessments due for the current month
15. Less Prepaid Credit: Any amount that was overpaid in a previous month should be written here
16. Remaining Balance Due: Take the "Total Assessments Due" and subtract any "Prepaid Credit" to get the remaining balance due for the month
Part C: Total Dollar Value of Pounds Marketed as Fresh: Write-in the total dollar value of those mushrooms being sold to the fresh market
Signing the report: The person that signs the report may be different from the person who prepares the report. The person who is authorized in your company should print their name and sign as well as write their title and date of signature. If submitting this form electronically, digital signatures will be accepted. 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.
Late Payment Fees: This report and assessment payment must be postmarked or received by the Mushroom Council within 15 days (due date) after the end of the month such mushrooms were marketed. Any report not postmarked within 15 days after the end of the month assessments are due will be assessed a one-time late payment charge of 10 percent. In addition to the late payment charge, a 1.5 percent per month (18 percent per annum) interest charge will be added to any account delinquent beyond the last day of the second month following the month the mushrooms involved were marketed and will continue monthly until the outstanding balance is paid to the Mushroom Council. All reports are held in strict confidence by the Mushroom Council.
1209.61 Book and Records: Each persons who is subject to this subpart shall maintain and make available for inspection by the Council or the Secretary such books and records as are deemed necessary by the Council, with the approval of the Secretary, to carry out the provisions of this subpart and any rules and regulations issued hereunder, including such books and records as are necessary to verify any reports required. Such books and records shall be retained for at least two years beyond the fiscal year of their applicability.
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 Mushroom Promotion, Research, and Consumer Information Act of 1990 (7 U.S.C. §§6101-6112). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) 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.
MUS-FHR (Expiration Date XX/XX/20XX)		Page 4 of 4