LP-3 American Egg Board Producer/Handler Exemption Registrati

0MB NO. 0581-0093

Certificate of Laying Hens Exemption Form American Egg Board

This report must be filled out correctly and completely. The information requested is required to make a determination concerning a producer's eligibility for exemption as specified by §1250.348. Failure to report can result in a fine. Information provided in this report is held confidential under §1250.341. Any false statements or misrepresentation may result in a fine of not more than $10,000, or imprisonment for not more than

5 years or both (18 U.S.C. §1001).

Producer Company Name		Flock Owner If Different
Authorized Officer Name		Phone
Mailing Address		Email
City, State, Zip		Fax
Flock Owner Tax ID

Reason for claiming exemption status:

I am an egg producer owning a flock of breeding hens whose production of eggs is primarily utilized for the hatching of baby chicks.

I am an egg producer whose aggregate number of laying hens at any time during a 3·month consecutive period

immediately prior to the date assessments are due and payable has not exceeded 75,000 laying hens.

The aggregate number of laying hens owned by a trust or other type of entity shall be considered ownership by the beneficiaries whose ownership is 50 percent or more in that trust or other type of entity.

New collecting handlers shall register with AEB within 30 days following the beginning of operations.

Producer's who qualify for exemption, must submit this form to each collecting handler annually on or before January 1, as long as the producer continues to do business with the collecting handler. A copy of this Certificate of Exemption shall be forwarded to AEB by the collecting handler within 80 days of receipt from the producer.

If the exempt producer no longer qualifies for an exemption as specified in §1250.348 or §1250.530, that producer shall notify,

within 10 days, all handlers with whom the producer has filed the Certificate of Exemption including AEB.

This information is required for exemption status determination:

Aggregate number of laying hens for the last 3-month consecutive period: Month 1: __________; Month 2: __________; Month 3: __________

STATEMENT OF CERTIFICATION

I hereby certify, under the penalties provided by law, that the information provided in this report are true, correct and complete . I

also certify that I am authorized to sign this form.

________________________________ ___________________________ _________________

Signature ^{Title Date}

Collecting Handler Information

Handler ID

Company Name Handler Contact

Mailing Address __________________________________________________________

Return form to:

American Egg Board ATTN: Assessments Street

Suite #

City, State, & Zip

Phone: (847) 296-7043

City State Zip

Email: ____________________________ Phone ______________ Fax _____________

Please include the farm address if different than the mailing address.

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Fax: (847) 296-7007

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 10 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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