XMAS-AE Application for Exemption from Assessment

Application for Exemption Request Form Christmas Tree Promotion Board					OMB No. 0581-0268
The information on this form is required to make a determination concerning a person’s eligibility for exemption from assessments from the Christmas Tree Promotion Board (CTPB) as provided in 7 CFR 1214.53.
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:
City/State/Zip code:			E-mail:
Tax ID #			Importer ID #
Acres Planted to Christmas Trees			Number of Trees Sold 20XX
Certification Statement I hereby certify that I cut and sold in the United States or imported to the United States less than 500 Christmas trees in 20XX. I therefore request a certificate of exemption from the Christmas Tree Promotion Board. ____________________________ _____________________________ _____________ 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 five years, or both.
Please keep a copy for your records and submit this form to:		Christmas Tree Promotion Board Street Address City, State, Zip Phone (xxx) xxx-xxxx Email
Applicant shall maintain any books and records necessary to verify information on this application. Such books and records must be made available during normal business hours for inspection by the CTPB. All information obtained from books, records, or reports will be kept confidential by the CTPB staff. Such information shall not be available to CTPB members, producers or importers.
Upon receipt of your Application for Exemption, the CTPB will make a determination whether an exemption may be granted. The CTPB will issue, if deemed appropriate, a Certificate of Exemption letter stating that should your sales ever meet or exceed the 500 tree exemption threshold, you will be responsible for filing a sales report and sending payment of assessments in accordance with the Order (7 CFR 1214), by February 15th in the year following harvest.

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 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 Tax Identification Number (TIN) or Business Identification Number is mandatory, and will be used to determine affiliation or entity identification.

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 0581-0268. 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, 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.

XMAS-AE (02/20) Destroy previous editions

Exp. Date XX/XX/XXXX