MUS-AFR Mushroom Importer Application for Refund of Assessment

OMB No. 0581-0093

IMPORTER APPLICATION FOR REFUND OF ASSESSMENT

MUSHROOM PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER (7 CFR 1209)

PLEASE READ THE INSTRUCTIONS THE REVERSE SIDE OF APPLICATION

BEFORE COMPLETION (PLEASE TYPE OR PRINT)

Name of Applicant	Business Telephone No. (include area code)
Name of Business
Business Address City State Zip

_____________________________________ _____________________________________

(Importer No. or Broker No. Tax ID No.) (Certificate of Exemption No.)

Port of Entry and Entry No.	Entry Date	Quantity (Kilograms)	Assessment Collected

Total amount of assessment collected to be refunded:________________________

A refund is hereby requested for the assessment collected by the U.S. Customs Service and paid to the Mushroom Council on the above-described mushrooms. I certify that the above information provided in this application for refund is true and correct to the best of my knowledge and I have not previously applied for a refund on the above listed mushrooms. I further certify that I am authorized to file this application on behalf of the aforementioned business. 1/

_________________________________________ ____________________________________________

Name of Applicant (Print) Title

X_________________________________________ ____________________________________________

Signature of Applicant Date

1/ 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.

MUS-AFR (rev. 03/17) Destroy previous editions.

INSTRUCTIONS

RECEIPTS OR COPIES THEREOF MUST BE ATTACHED TO THIS APPLICATION

Return to the Mushroom Council

Street

City, State Zip

Receipts or copies thereof, submitted with this application will not be returned. Type or Print this application. Attach additional pages if necessary.

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 Mushroom Promotion, Research, and Consumer Information Act of 1990 (7 U.S.C. 6101-6112). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) 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/hours 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.

MUS-AFR (rev. 03/17) Destroy previous editions.