Form AMS-23 State and Tribal Hemp Producer Report

REPRODUCE LOCALLY. STATE AND TRIBAL PRODUCER REPORT.

OMB No. 0581-0318

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
USDA DOMESTIC HEMP PRODUCTION PROGRAM
STATE AND TRIBAL PRODUCER REPORT
Reporting Period: _________________ to _________________
State or Tribe Name: ________________ Date Submitted: __________
The USDA Domestic Hemp Production Program requires States and Tribes with approved hemp
production plans to submit contact information and license status for each licensee.
Instructions:
The purpose of this report is to collect information from States and Tribes on licensees. This
form must be submitted to USDA on the 1st day of each month. If this date falls on a holiday or
weekend, the reports are due the next business day.
Below is a description of each data point needed:
•

Name of Licensee: Provide the name of the licensee as it appears on the license. This can
be the name of an individual, a business entity, or a research institution.

•

License Number: Provide the license or authorization number as it appears on the license.

•

Date of License Issuance: Provide the date of license issuance.

•

Date of License Expiration: Provide the date of license expiration.

•

Employer Identification Number (EIN): Provide the employer identification number as
issued by the Internal Revenue Service. This is for business entities only. Do not provide
social security numbers.

•

Mailing Address: Provide the address of the licensee.

•

Telephone: Provide the telephone number of the licensee.

•

E-mail: Provide the e-mail address of the licensee.

•

License Status: Provide the status of the license. The options are “active,” “suspended,”
“revoked,” or “inactive.”

•

Corrective Action Plan: Provide a yes or no answer on whether the licensee is operating
under a corrective action plan as defined under 7 CFR Part 990.

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REPRODUCE LOCALLY. STATE AND TRIBAL PRODUCER REPORT.

OMB No. 0581-0318

This form shall be submitted to the USDA using a digital format compatible with USDA’s
information sharing systems, whenever possible. All information submitted must be accurate,
legible, and complete. If submission through USDA information sharing systems are not
possible, please submit form to:
By Mail:

USDA/AMS/Specialty Crops Program
Hemp Branch
470 L’Enfant Plaza S.W.
Post Office Box 23192
Washington, D.C. 20026

Or via Email at:
Forms.Hemp@usda.gov

Or via Fax at:
(202) 720-8938

The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552a) and the
Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is
the 7 CFR Part 990 Domestic Hemp Program (Program). The purpose of collecting this information is for
USDA to administer the Program and the information provided on this form will be used to monitor Program
participants. Failure to provide the information requested on this form may result in ineligibility to participate
in the Program.
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 OMB 0581-0318. The time required to complete this information collection is estimated to average 60 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.
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REPRODUCE LOCALLY. STATE AND TRIBAL PRODUCER REPORT.
Name of
Licensee

License or
Authorization
Number

Date of
License
Issuance

Date of
License
Expiration

EIN
(if applicable)

OMB No. 0581-0318
Mailing Address

Telephone #

E-mail
Address

Status of License
(Active, Suspended
Revoked, Inactive)

On Corrective
Action Plan?
(Yes or No)

Use additional line as necessary.

AMS-23 (XX/20XX) Exp: XX/20XX

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