Form AMS-15 Organic Exemption

Organic Exemption Request Form American Pecan Promotion Board							OMB No. 0581-0093
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 and/or  Importer (mark as appropriate)
Please complete the following:
Applicant’s First and Last Name:
Company name:					Phone:
Street address:					Fax:
City/State/Zip code:					E-mail:
Tax ID #					Importer ID #
In order to be exempt, the above-named entity 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 and/or imports products eligible to be labeled “organic” or “100% 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 entity’s organic farm or organic handling operation certificate and addendum provided by a USDA-accredited certifying agent under the OFPA must be attached. Importers should attach a copy of a certificate or equivalency agreement for the eligible product as established under NOP.
Certification Statement I hereby certify that my annual U.S. production and/or importation of pecans is an estimated total ___________ pounds, with _____________ pounds “organic” and/or “100% organic” and ___________ pounds non-organic (or conventional). (Organic and non-organic pounds should equal total pounds). ____________________________ _____________________________ _____________ Signature Title Date the making of any false statement or representation on this form, knowing it to be false, is a violation of title 18, section 1001 United states code, which provides for the penalty of a fine of $10,000 or imprisonment of not more than 5 years, or both .
Please return this form to:				American Pecan Promotion Board Street Address City, State Zip Phone (xxx) xxx-xxxx

AMS-15 (Rev. 12/15) Destroy previous editions. See reverse for burden/non-discrimination statement

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 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 importer 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.

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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].

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