MAN-AAE Mango Application for Certificate of Exemption

OMB No. 0581-0093

APPLICATION FOR A CERTIFICATE OF EXEMPTION
MANGO PROMOTION, RESEARCH, AND INFORMATION ORDER
(7 CFR 1206)

YEAR BEING APPLIED FOR:

20XX

PLEASE READ THE INSTRUCTIONS AT BOTTOM OF THIS APPLICATION
PLEASE TYPE OR PRINT
APPLICANT'S NAME

BUSINESS TELEPHONE NO., INCLUDE AREA CODE

BUSINESS NAME

BUSINESS ADDRESS

CITY

STATE

ZIP

TAX ID# or Employer ID#

I hereby CERTIFY that:
_ I am a first handler and I handled
_ I am an importer and I imported

pounds of mangos during the year 20XX.
pounds of mangos during the year 20XX.

________________________________________________________________ _______________________________________
Name of Applicant (Print)
Title
_______________________________________
Date

Signature of Applicant

***************

INSTRUCTIONS

***************

Return to:
National Mango Board
Street
City, State Zip

If you are a first handler or importer of mangos, and you handled or imported less than 500,000 pounds during the previous year,
you are eligible to claim an exemption from assessments. The National Mango Board will require persons applying for an exemption
from assessments to provide substantiating information supporting their exemption status. All persons are liable for paying
assessments, except those who have a Certificate of Exemption issued by the National Mango Board and must be renewed annually
by the National Mango Board.
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.

MAN-AAE (03/17) Destroy previous editions.

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. 104127, 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 importer 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 0581-0093. 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.

MAN-AAE (Rev. 03/17) Destroy previous editions.