No Form Number American Egg Board Producer/Handler Exemption Registrati

OMB No. 0581-0093

AEB Producer/Handler Exemption Registration Form
You must notify AEB if your layer numbers go above the exemption limit

Important Notice:

Each handler receiving such certification form shall within 30 days forward a copy to: American Egg Board;
Address, City, State, and Zip. If the exempt producer becomes subject to assessment pursuant to section
1250.14 of the Rules and Regulations, he shall notify all handlers with whom he has filed a certificate of
exemption during the past 12 months.

ATTN: Handlers...
This form must be filed at the time of initial registration and annually thereafter as long as you, the handler, continue to purchase and/or
handle eggs only from exempt producers as described in section 1250.514 of the Rules and Regulations implementing the Egg Research
and Promotion Order.

ATTN: Producers...
This form also serves as a certification form that shall be filed with each handler within 10 days after the first sale of eggs to such
handler after August 1, 1976, and annually thereafter on or before January 1, as long as the producer continues to do business.

Who is exempt? You must comply with one of these options: (Check one)

□

I handle eggs only from producers with 75,000 layers or less. (Exemptions from those producers must
be submitted with your form).

□

I am a combined producer/handler. I have 75,000 birds or less and I process only my own eggs.

□

I am a producer only (I do not wash, grade, or carton eggs). My aggregate number of laying hens at any
time during the three consecutive-month period immediately prior to the month in which assessments are due
and payable has not exceeded 75,000 laying hens. (Note: You must state below to whom you’re selling
eggs.)

□

I am a producer claiming exemption because my eggs are from a flock of breeding hens, whose egg production
is primarily utilized for the hatching of baby chicks.

Producer applying for exemption

List handler of the eggs (must be completed)
Name:

Name:

Address:

Address:

City, St, Zip:

City, St, Zip:

Phone:
Email:

Fax:

Phone:

Fax:

Email:

Certification Statement

I certify that at the signing of this statement and for the signed date that the above statement is true.

______________________________            ___________________________________      ___________________________ 
Signature
Title
Date

Flock Information 

You must complete this information as part of your exemption request.  Fill in lines for your average flock size and the number of eggs 

  produced during the past 3 months.  This information is needed to support your claim.   
  Average number of layers during the past 12 months_______________________________ 
____________ 
  30 dozen cases of eggs produced during the past 3 months.  ____________  ____________ 

            1                               2                                    3 

Return this form to:  American Egg Board 

“Information collection is supervised by the U.S. Department of  
                                      P.O. or Street 

                                    Agriculture. Certification is required in order to receive exempt status 
                                      City, State  Zip                                                        (7 U.S.C. 2707 (e)).  Information held confidential (7 U.S.C. 2706 (c)). 
                                       Phone #       Fax #                                    

LPS (Rev. 04/17)   

 See reverse for burden/non-discrimination statement

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 10 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintain the data needed, and completing and review 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.

(Rev. 04/17)