PEA-FHR Peanuts - First Handler Report - Fee Collection

NATIONAL PEANUT BOARD OMB No. 0581-0093

First Handler Report

Peanut Promotion, Research, and Information Order - Fee Collection

This form may be completed as below, or serve as a cover sheet with just totals, with all details attached. Please submit hard copy or in electronic format.

(Name) (Business Telephone No., Include Area Code)

(Name of Business/Company) (Tax ID No. or Employer ID No.)

(Business Address) (City) (County) (State) (Zip)

Report of Peanuts Handled During , 20XX (Month)

List Below the Producers for Whom you Handled Peanuts -- REMEMBER TO SORT BY STATE

Crop Year

Producer name

Address

City

State

Zip

FSA State ID

FSA County ID

FSA Farm #

Farm Name

Purchase Price

Purchase Date

# Tons Purchased

Price Per ton

Segregation (1, 2 or 3)

Assessment*

*Assessment = (Seg.1 Tons purchased x $x.xx) or (Seg.2 Tons purchased x $x.xx) or (Seg.3 Tons purchased x $x.xx)

I certify under the penalties provided by law, that this report is true, correct, and complete report. I also certify that I am authorized to sign this report.¹

Name of Individual - Print Title

Signature of Individual Date

¹Any 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).

PEA-FHR (Expiration Date XX/XX/20XX) See reverse for burden/non-discrimination statement

OMB No. 0581-0093

INSTURCTIONS

For peanuts placed in the Marketing Assistance Loan (MAL) program the assessment is collected and remitted by USDA/Farm Service Agency. If the peanuts are not placed in the MAL program, first handlers shall collect from producers or first purchasers/handlers and pay assessments to the National Peanut Board (NPB) no later than 60-days after the last day of the month in which the peanuts were marketed. First handlers must complete this form or attach a list or CD of the producers for whom you handled peanuts and remit assessments to NPB at the address below within 60-days or a late payment fee will be assessed. If you submit a list or CD of producers, please complete the other portions of the form and remit with the assessments to NPB.

Mail this report with payment in full to: National Peanut Board

Attn: XXX
Street
City, State Zip
Telephone: XXX-XXX-XXXX

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 Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 1 10 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 Employer Identification Number (EIN) 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 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.

PEA-FHR (Expiration Date XX/XX/20XX)