PAP-AAE Paper-Application for Exemption From Assessment

OMB No. 0581-0093

PAPER AND PAPER-BASED PACKAGING PROMOTION, RESEARCH, AND INFORMATION BOARD

APPLICATION FOR EXEMPTION FROM ASSESSMENT

Section 1222.53 of the Paper and Paper-Based Packaging Promotion, Research, and Information Order provides that any domestic manufacturer or importer who manufactured or imported into the United States less than 100,000 short tons of paper or paper-based packaging during the prior marketing year is exempt from paying assessments and shall apply to the Paper and Packaging Board (Board), on a form provided by the Board, for a certificate of exemption. Such domestic manufacturer or importer shall certify that the manufacturer’s or importer’s shipment or importation of paper and paper-based packaging shall be less than 100,000 short tons for the marketing year for which the exemption is claimed.

CERTIFICATION

(To Be Signed and Dated by Applicant)

I hereby certify that I manufactured within the United States or imported into the United States less than 100,000 short tons of paper and paper-based packaging in 20XX (prior year). I therefore request a certificate of exemption from the Board for the year 20XX. (current year)

Signature ____________________________________ Date: ________________

Please Print

Name of Applicant: _________________________________________________

Company Name: _________________________________________

Street Address: ______________________________________________________

City: ________________________________ State: ________________________

Zip Code: ____________________ Telephone No. _________________________

Email: _________________________________________________

Tax ID or Importer No.: _________________________________

Please mail your completed Certificate of Exemption Application with supporting documentation to verify prior year’s shipments/imports to the Board at the following address:

Paper and Packaging Board

Street Address

City, State Zip

Attention: Assessments

Email:

OMB No. 0581-0093

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, 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 Business 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, 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.

PAP-AAE (Expiration Date XX/XX/20XX)

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