AMS-15 (Grass Sod)

Organic Exemption Request Form OMB No. 0581-NEW Natural Grass Sod Board
The information on this form is required to make a determination concerning a person’s eligibility for exemption from assessments under research and promotion programs.
Type of Operation:  Producer (mark as appropriate)
Please complete the following:
Applicant’s First and Last Name:
Company name:			Phone:
Street address:			Fax:
City/State/Zip code:			Email:
Tax ID #
In order to be exempt, the above-named company must meet all of the following (please check): Operates under an approved organic system plan authorized under the USDA-AMS organic regulations (7 CFR Part 205) and maintains a valid organic certificate issued by an AMS accredited certifying agent. Produces products eligible to be labeled “organic” or “100 percent organic” under the USDA organic regulations. Is subject to assessments under the research and promotion program for which this exemption is requested.
	A copy of this company’s organic farm or organic handling operation certificate and addendum provided by a USDA-accredited certifying agent under the OFPA must be attached.
Certification Statement I hereby certify that my annual production of natural grass sod is an estimated total _________ pounds with __________ pounds “organic” and/or “100 percent organic” and ________ pounds non-organic (or conventional). I hereby certify that my annual sales of finished sod products are an estimated total _________ pounds with _________ pounds “organic” and/or “100 percent organic” and ___________ pounds non-organic (or conventional). (Organic and non-organic pounds should equal total pounds.) Signature Title Date Any 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).
Natural Grass Sod Board Street Please return this form to: City, State, and Zip Phone: (XXX) XXX-XXXX Email:

AMS-15 (Expiration Date XX/XX/XXXX) See reverse for burden/non-discrimination statement

The following statements are made in accordance with the Privacy Act of 1974 (5 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 from the applicable commodity legislation for research and promotion programs. Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or other unique identification number is mandatory and will be used to determine affiliation or entity identity.

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, 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.

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 Producer