No Form Number Cotton--Application for Reimbursement of Assessment on I

Print Form

Application for Reimbursement
of Assessment on Imported Cotton and
Cotton Content of Imported Products

OMB No. 0581-0093
EXPIRATION DATE: XX/XX/XXXX

Cotton Board
5050 Poplar Avenue
Suite 1900
Memphis, TN 38157

Reimbursement No.
For CB Office purposes only

Phone: (901) 683-2500
Fax: (901) 685-1401
Importer of Record Name and Address:

Reimbursement Mailing Address:
Name

Name

Address

Address
City

State

Zip

City

State

Zip

Customs Importer Identification No.

Telephone
Contact Person

Check Appropriate Category:

U.S. Produced Cotton

No Cotton Content

Extra Long Staple Cotton

Corrections

Description of Merchandise*
10 Digit HTS Classification
of the Imported Product

Continued on page 2

Net Weight
In Kilograms

$ Amount of
Cotton Fee Paid

Date Fee
Was Paid

I have attached a separate spreadsheet with this information

Customs District of Entry

Exporting Country

Country of Origin

Total Reimbursement Requested $
Certification: I declare that the information provided in this application is true and correct to the best of my knowledge. If any information changes
after submission of this application, I will immediately notify the Cotton Board.
Please print and sign below.
Printed Name

Signature

Date

*Attach a copy of the U.S. Customs and Border Protection form 7501 Entry Summary and Commercial invoices or other such documentation in english indicating the origin of the
production or type of the cotton fiber used to produce the imported product.
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.
USDA’s Nondiscrimination Statement
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.

Description of Merchandise - Continued*
10 Digit HTS Classification
of the Imported Product

Net Weight
In Kilograms

$ Amount of
Cotton Fee Paid

Date Fee
Was Paid

Please enter the total $ Amount of Cotton Fee Paid on page 1.
*Attach a copy of the U.S. Customs and Border Protection form 7501 Entry Summary and Commercial invoices or other such documentation in english indicating the origin of the
production or type of the cotton fiber used to produce the imported product.
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.
USDA’s Nondiscrimination Statement
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.