Form PAP-PIQ (Order) PAP-PIQ (Order) Production/Import Quarterly Report

OMB No. 0581-NEW

Payment Due On or Before: ___________

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

(7 CFR 1222)

PRODUCTION/IMPORT QUARTERLY REPORT

For the ____ Quarter (Please specify)

(Quarters are as follows: 1 = Jan, Feb, Mar; 2 = Apr, May, Jun; 3 = Jul, Aug, Sep; 4 = Oct, Nov, Dec)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. 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 the Tax Identification Number is mandatory, and will be used to determine affiliation or entity identification.

Contact Person:

Company Name:____________________________ Tax ID# or Business ID#:

Address:

City:_____________________________ State:___________________ Zip Code:

E-mail:____________________________________ Web site:

Telephone Number:__________________________ Fax No.

* For domestic manufacturers, if plant location differs from the address above, please specify plant address:

___________________________________________________________________________________

Enter the quantity of short tons of paper and paper-based packaging manufactured within the United States during the applicable quarter, by type:

	Printing, writing and related papers	Kraft packaging papers	Containerboard	Paperboard	Total
Short tons

Enter the quantity of short tons of paper and paper-based packaging imported into the United States during the applicable quarter and country of origin, by type:

	Printing, writing and related papers	Kraft packaging papers	Containerboard	Paperboard	Total
Short tons by country of origin

Deduct quantity of short tons exempt from assessment:

TOTAL NUMBER OF SHORT TONS ON WHICH

ASSESSMENT IS DUE:

(Total Manufacture and/or Imported minus exempt amount = Total short tons to be assessed)

Assessment rate ($0.XX per short ton) X $0.XXX

TOTAL ASSESSMENT DUE:

I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.XXX per short of paper and paper-based packaging manufactured or imported during this reporting period for which I am required to pay the assessment. I also certify that I am authorized to sign this report.

Print Name and Title of Person Completing this Report

Signature Date

Please Mail to: Paper and Paper-Based Packaging Promotion, Research, and Information Board

Street, City, State, Zip Code

Continue to next page for further instructions.

INSTRUCTIONS

Domestic manufacturers are required to pay assessments and file this report no later than the thirtieth calendar day of the month following the end of the quarter in which the paper and paper-based packaging was manufactured. The fiscal year runs from January through December. There are four quarters in each fiscal year. Quarter 1 covers January, February and March. Quarter 2 covers April, May, and June. Quarter 3 covers July, August, and September. Quarter 4 covers October, November, and December. Assessments for paper and paper-based packaging manufactured during Quarter 1 are due by April 30; for Quarter 2 by July 30; for Quarter 3 by October 30, and for Quarter 4 by January 30. Importers of paper and paper-based packaging shall pay through Customs; however, if Customs does not collect an assessment from the importer, the importer is responsible for paying the assessment directly to the Board and submitting this report to the Board with the assessment payment. All reports are held in strict confidence by the staff of the Board and the U.S. Department of Agriculture (USDA).

This report is required by law [7 U.S.C. 7416, 7 CFR Part 1222.52 and 7 CFR Part 1222.70]. Failure to report can result in a fine of not less than $1,000 or more than $10,000 for each such violation. Each such violation shall be deemed a separate violation. 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 five years, or both.

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-NEW. 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (not all prohibited bases apply to all programs). Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C.20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

PAP-PIQ (02/12)