BLU-AAE Blueberry Application for Exemption from Assessment

Approved - OMB No. 0581-0093

U.S. HIGHBUSH BLUEBERRY COUNCIL

APPLICATION FOR EXEMPTION FROM ASSESSMENT

As stated in section 1218.53 of the Blueberry Promotion, Research, and Information Order (Exemption Procedures):

“Any producer who produces less than 2,000 pounds of blueberries annually who desires to claim an exemption from assessments during a fiscal year as provided in section 1218.42 shall apply to the U.S. Highbush Blueberry Council (USHBC), on a form provided by USHBC, for a certificate of exemption. Such producer shall certify that the producer’s production of blueberries shall be less than 2,000 pounds for the fiscal year for which the exemption is claimed. Any importer who imports less than 2,000 pounds of fresh and processed blueberries annually who desires to claim an exemption from assessments during a fiscal year as provided in section 1218.52 shall apply to USHBC, on a form provided by USHBC, for a certificate of exemption. Such importer shall certify that the importer’s importation of fresh and processed blueberries shall not exceed 2,000 pounds, for the fiscal year for which the exemption is claimed.”

CERTIFICATION

(To Be Signed and Dated by Applicant)

I hereby certify that my total level of blueberry production in 20XX, or the total fresh or processed blueberries I will import in 20XX, will be less than 2,000 pounds. I therefore request a certificate of exemption from USHBC assessments for the year 20XX.

Signature ____________________________________ Date: ________________

Please Print

Name of Applicant: _________________________________________________

Company Name (if applicable): _________________________________________

Street Address: ______________________________________________________

City: ________________________________ State: ________________________

Zip Code: __________ Phone: _________________ Email: ___________________

Please send your completed Certificate of Exemption Application to USHBC at the following address:

USHBC

Street

City, State Zip

BLU-AAE (Expiration Date XX/XX/20XX) See reverse for burden/non-discrimination statement

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 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

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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.

BLU-AAE (Expiration Date XX/XX/20XX)