Pima Cotton Agriculture Trust Fund

For Pima Agriculture Cotton Trust OMB No.: 0551-0044

Expiration Date:

Affidavit of Yarn Spinner to Claim Payment from

The Pima Agriculture Cotton Trust Fund in 2021

Filed pursuant to section 12314 of the Agricultural Act of 2014

(P. L. 113-79)

1. The undersigned, __________________________________, certifies and affirms that I am _____________________ of ____________________________________, an officer of a company that produces ring spun yarns in the United States measuring less than 83.33 decitex (exceeding 120 metric number), in single and plied form from pima cotton.

2. I certify and affirm that ______________________________________ produces yarns of pima cotton at its facility located at ___________________________________________

_________________, including ring spun cotton yarns measuring less than 83.33 decitex (exceeding 120 metric number), in single and plied form from pima cotton during the period January 1, 2020 through today, and during calendar year 2020.

3. I certify and affirm that ____________________________________________ produced __________________ pounds of ring spun cotton yarns, measuring less than 83.33 decitex (exceeding 120 metric number), in single and plied form during calendar year 2020.

4. I certify and affirm that ___________________________________________ maintains supporting documentation showing the quantity of such yarns produced, and evidencing the yarns as ring spun cotton yarns, measuring less than 83.33 decitex (exceeding 120 metric number), in single and plied form during calendar year 2020.

5. I certify and affirm that ___________________________________________ purchased $_______________________ of pima cotton that was used in spinning any cotton yarns during calendar year 2020.

6. I certify and affirm that ___________________________________________ maintains supporting documentation showing the dollar amount of pima cotton purchased that was used in spinning any cotton yarns during calendar year 2020.

I certify and affirm that to the best of my knowledge and belief all information contained in this claim and affidavit is complete and correct and no false claims, statements, or representations have been made.

____________________ __________________________________

Date Signature

­­­­­­­­­­­­­­­­__________________________________

Title

__________________________________

Company Name

__________________________________

__________________________________

Address

( State of____________________________

( County/City of ______________________

___________________________ subscribed and sworn to before me this affidavit for a claim for payment from the Pima Agriculture Cotton Trust Fund this ________ day of

________________, 2021.

Signature of Notary Public

______________________________________

My Commission expires __________________

E-Mail completed and notarized form to: [email protected]

Public reporting for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection of information are voluntary, and will be provided confidentiality to the extent allowed under the Freedom of Information Act. Notwithstanding any other provision of the law, no person is required to respond to nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless the collection of information displays a current valid OMB control number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Program Operations Division at: [email protected]

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