AMS-15 Organic Exemption Request Form (OMB 0581-0093)

Organic Exemption Request Form [Insert board/council name here]							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: Insert appropriate program operations. See supplemental list. (Boards that assess only one type of operation may omit this section.)
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 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/handles/imports/manufactures/feeds/exports/processes) 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 company’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. (Boards that do not assess importers may delete the second sentence.)
Certification Statement I hereby certify that my annual (basis of assessment, including but not limited to production, processing, importation) is an estimated total ___________ (lbs., tons, value, etc), with _____________ (lbs., tons, value, etc.)“organic” and/or “100% organic” and ___________(lbs., tons, value, etc.) non-organic. 1 ____________________________ _____________________________ _____________ Signature Title Date 1/ Any false statement or misrepresentation may result in a fine of not more than $10,000, or imprisonment for not more than 5 years or both (18 U.S.C. 1001).
Please return this form to:				[Insert Board/Council/other entity] ______________________________ ______________________________

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.

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: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.

AMS-15 Supplemental List

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Type of Operation Selections:

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 Producer  Handler  First Handler  Processor  Importer  Exporter

 Seed Stock Producer  Feeder  Domestic Manufacturer