MAN-AAE Mango Application for Certificate of Exemption

OMB No. 0581-0093

APPLICATION FOR A CERTIFICATE OF EXEMPTION

MANGO PROMOTION, RESEARCH, AND INFORMATION ORDER

(7 CFR 1206)

YEAR BEING APPLIED FOR: 20XX

PLEASE READ THE INSTRUCTIONS AT BOTTOM OF THIS APPLICATION

PLEASE TYPE OR PRINT

APPLICANT'S NAME	BUSINESS TELEPHONE NO., INCLUDE AREA CODE
BUSINESS NAME
BUSINESS ADDRESS	CITY STATE ZIP
TAX ID# or Employer ID#

I hereby CERTIFY that:

_ I am a first handler and I handled pounds of mangos during the year 20XX.

_ I am an importer and I imported pounds of mangos during the year 20XX.

________________________________________________________________ _______________________________________

Name of Applicant (Print) Title

_______________________________________

Signature of Applicant Date

*************** INSTRUCTIONS ***************

Return to:

National Mango Board

Street

City, State, Zip Code

If you are a first handler or importer of mangos, and you handled or imported less than 500,000 pounds during the previous year, you are eligible to claim an exemption from assessments. The National Mango Board will require persons applying for an exemption from assessments to provide substantiating information supporting their exemption status. All persons are liable for paying assessments, except those who have a Certificate of Exemption issued by the National Mango Board and must be renewed annually by the National Mango Board.

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.

OMB No. 0581-0093

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