SC-265 Application for Certification of Peanut Organization

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 058 1-0093. 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.

INSTRUCTIONS: Please print or type in all applicable spaces and sign your name. The following information is to be submitted by each peanut organization that applies for certification to submit nominations for National Peanut Board membership to the Secretary of Agriculture and/or to submit requests for funding to the National Peanut Board. Attach separate sheets of paper as necessary (make reference to appropriate question number(s).

1a. NAME OF APPLICANT ( Organization )

1b. MAILING ADDRESS (Number, Street, City, State, ZIP Code)	1c. TELEPHONE NO.			(Include area code)
	1d.	FAX	NO.	N
	1e. EMAIL ADDRESS

2a. NAME OF CHAIRPERSON OR OTHER CHIEF ELECTED OFFICIAL

2b. TITLE

2e. EMAIL ADDRESS

3a. NAME OF CHIEF STAFF OFFICER

3b. TITLE

3e. EMAIL ADDRESS

________________________________________________________________________________________________________________________________ __
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4. PLEASE CHECK THE REASON(S} FOR THIS APPLICATION: (Mark an "X" on appropriate line) _{NOMINATIONS_____ FUNDS _____}

5a. IS THIS PEANUT PROMOTION ENTITY AUTHORIZED BY STATE STATUTE? (Mark an "X" on appropriate line) _{YES NO}

5b. IF "YES", ATTACH A COPY OF THE RELEVANT STATUTE AND PROVIDE THE FOLLOWING:

6a. DOES THIS APPLICANT CURRENTLY RECEIVE ASSESSMENTS OR CONTRIBUTIONS FROM PRODUCERS? (Mark an "X "On appropriate line)

YES NO ____

6b. IF "YES," DESCRIBE THE ASSESSMENT RATE OR THE BASIS FOR CONTRIBUTIONS (rate per ton, percent of price, etc.)

6c. DESCRIBE THE MANNER IN WHICH THE APPLICANT ASSESSES (Attach separate sheet of paper):

1. Peanuts grown in applicant’s State, but sold in another State; and

2. Peanuts grown in a State other than the applicant’s State, but sold in the applicant’s State.

6d. ARE ANY PEANUTS EXEMPT FROM ASSESSMENT? (Mark an "X " on appropriate line) _{YES NO _____}

6e. IF "YES", EXPLAIN BELOW OR ON SEPARATE SHEET OF PAPER:

7. DOES THIS APPLICANT CURRENTLY CONDUCT ANY OF THE FOLLOWING IN-STATE AND/OR ON A NATIONAL BASIS'

(Mark an "X " in appropriate box(es)

	IN-STATE	NATIONAL
a. Promotion
b. Research
c. Consumer Information
d. Industry Information

IF 7a THROUGH 7d DO NOT APPLY, SKIP TO QUESTION 7f.

7e. ARE ANY OF THE PROGRAMS REFERRED TO IN QUESTIONS 7a THROUGH 7d INTENDED TO STRENGTHEN THE PEANUT INDUSTRY'S
POSITION IN THE MARKET PLACE? (Mark and “X” on the appropriate line)

YES NO_____

7f. IF THE APPLICANT HAS NOT YET COLLECTED ASSESSMENTS FROM PRODUCERS, OR HAS NOT YET CONDUCTED A PROGRAM OF PEANUT PROMOTION, RESEARCH, CONSUMER INFORMATION, AND/OR INDUSTRY INFORMATION, DESCRIBE IN DETAIL THE CURRENT PLANS, NOT DISCUSSED ELSEWHERE IN THIS APPLICATION, TO IMPLEMENT SUCH A PROGRAM AND THE PROJECTED DATE OF IMPLEMENTATION OF SUCH A PROGRAM (If not enough space below, attach separate sheets of paper for description).

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8a DESCRIBE ON SPEARATE SHEET OF PAPER, THE MANNER IN WHICH ASSESSMENTS ARE (OR WILL BE) COLLECTED
FROM PRODUCERS IN YOUR STATE. INCLUDE THE FOLLOWING INFORMATION IN YOUR ANSWER:

1. Identification by job or title (i.e., Federal-State inspectors, markets, buyers, etc.), those persons or entities responsible for collecting assessments;

2. The procedures for accounting and remittance to the applicant by such collection persons;

3. Whether assessments are authorized by State law or established by organization action;

4. The time that such assessments are collected and the time period within which the collecting persons must remit the assessments to the applicant (or State agency on behalf of the applicant);

5. Whether the applicant will have any employees exclusively (or primarily) responsible for administering the collection as assessments; and

6. Any other information necessary to provide a thorough understanding of the manner in which this applicant collects assessments.

^{8b DESCRIBE ON SEPARATE SHEET OF PAPER, THE PROCEDURE(S) UTILIZED BY THE APPLICANT TO ENSURE THAT ASSESSMENT DUE FROM PRODUCERS ARE PAID. INCLUDE THE FOLLOWING INFORMATION IN YOUR ANSWER:}

1. Description of any compliance program established by the applicant (or a State agency on behalf of the applicant);

2. If assessments are not paid, the steps to be taken to secure payment; and

3. Any other information necessary to provide a thorough understanding of this entity’s efforts to ensure that assessments are paid.

9a. DOES THIS APPLICANT CERTIFY THAT IT WILL FURNISH TO THE NATIONAL PEANUT BOARD AN ANNUAL FINANCIAL REPORT BY A CERTIFIED PUBLIC ACCOUNTANT OF ALL FUNDS RECEIVED FROM THE NATIONAL PEANUT BOARD?

YES _____ NO _____

9b. DOES THIS APPLICANT CERTIFY THAT IT WILL FURNISH TO THE NATIONAL BOARD AN ANNUAL MARKETING PLAN?

YES ______ NO _______

9c. DOES THIS APPLICANT CERTIFY THAT IT WILL FURNISH TO THE NATIONAL BOARD ANY ADDITIONAL INFORMATION AND REPORTS THE BOARD
OR SECRETARY OF AGRICULTURE MAY REQUEST?

YES ______ NO _______

Yes □ No □

TOTAL BUDGET	$	EXPENDITURES ON CONSUMER INFORMATION	$
ADMINISTRATIVE EXPENSES	$
		EXPENDITURES ON INDUSTRY INFORMATION	$
EXPENDITURES ON PROMOTION	$
		EXPENDITURES FOR THE PURPOSE OF INFLUENCING LEGISLATION, GOVERNMANET ACTION, OR POLICY	$
EXPENDITURES ON RESEARCH	$

10b. DOES THIS APPLICANT AGREE THAT IT WILL NOT USE ANY FUNDS COLLECTED PURSUANT TO THE ACT AND THE ORDER FOR THE
PURPOSE OF INFLUENCING ANY LEGISLATION, GOVERNMENTAL ACTION, OR POLICY?

YES ______ NO _____

10c. DOES THIS APPLICANT AGREE THAT IT WILL NOT FINANCE, WITH FUNDS RECEIVED PURSUANT TO THE ACT AND THE ORDER, PLANS
OR PROJECTS WHICH ARE FALSE OR MISLEADING OR DISPARAGE ANOTHER AGRICULTURAL COMMODITY OR CREATE A CONFLICT OF
INTEREST?

YES ______ NO ______

_________________________________________________________________________________________________________________________ __

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11. LIST THE NAMES, ADDRESSES, AND TITLES OF ELECTED AND STAFF OFFICERS, AND ANY ORGANIZATIONAL TIES OF THE OFFICIALS OF THIS APPLICANT.

NAME	TITLE	ADDRESS	ORGANIZATION REPRESENTED

11. ENCLOSE A COPY OF APPLICANT’S MOST RECENT ANNUAL BUDGET, MARKETING PLAN, ANNUAL REPORT, AND FINANCIAL AUDIT.

11. PLEASE ATTACH ANY ADDITIONAL REMARK S WHICH MAY BE RELEVANT OR NECESSARY FOR THE SECRETARY TO DETERMINE WHETHER THE APPLICANT SHOULD BE CERTIFIED.

CERTIFICATION STATEMENT

I HEREBY CERTIFY that the information provided in response to the above items is true, complete, and correct to the best of my knowledge. I further state that I am authorized to submit this document on behalf of the applicant and to make the representations and certifications contained herein. The Secretary of the United States Department of Agriculture and the employees or agents of the National Peanut Board may examine our hooks, records, files, and facilities to verify any of the information submitted and may procure such other information as may be required to determine the applicant's eligibility for qualification.

SIGNATURE	PRINTED OR TYPED NAME
TITLE		DATE

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