No Form Number Cotton--Application for Exemption of Assessment on Impor

OMB No. 0581- 0093
EXPIRATION DATE: 06/30/2020

Print Form

Application for Exemption
of Assessment on Imported Cotton and
Cotton Content of Imported Products

Cotton Board
5050 Poplar Avenue
Suite 1900
Memphis, TN 38157

Exemption No.

For CB Office purposes only

Phone: (901) 683-2500
Fax: (901) 685-1401
Importer of Record Name and Address:

Exemption Mailing Address:
Name

Name

Address

Address
City

State

Zip

City

State

Zip

Customs Importer Identification No.

Telephone
Contact Person

Check Appropriate Category:

U.S. Produced Cotton

No Cotton Content

Extra Long Staple Cotton
Description of Merchandise*
10 Digit HTS Classification
of the Imported Product

Continued on page 2

Net Weight
In Kilograms

Date Fee
Was Paid

I have attached a separate spreadsheet with this information

Customs District of Entry

Exporting Country

Country of Origin

Certification: I declare that the information provided in this application is true and correct to the best of my knowledge. If any information changes
after submission of this application, I will immediately notify the Cotton Board.
Please print and sign below.

Printed Name

Signature

Date

*Attach commercial invoices or other such documentation in English indicating the origin of production or type of the cotton fiber used to produce the imported product(s). Also,
within 30 days of entry of the exempted goods referenced on this certificate, please submit a copy of the corresponding U.S. Customs and Border Protection 7501 form to the Cotton
Board.
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 30 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.
USDA’s Nondiscrimination Statement
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.

Description of Merchandise - Continued*
10 Digit HTS Classification
of the Imported Product

Net Weight
In Kilograms

Date Fee
Was Paid

*Attach commercial invoices or other such documentation in English indicating the origin of production or type of the cotton fiber used to produce the imported product(s).
Also, within 30 days of entry of the exempted goods referenced on this certificate, please submit a copy of the corresponding U.S. Customs and Border Protection 7501 form
to the Cotton Board.

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 30 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.
USDA’s Nondiscrimination Statement
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.