Evaluation and Compliance Form

OMB Control No. 0605-XNEW

Expiration Date: XX/XX/XXXX

United States Department of Commerce

Under Secretary for Economic Affairs

Quarterly Report of Concrete Masonry Products Production

Evaluation and Compliance Form

On a quarterly basis manufacturers of Concrete Masonry units are required to remit an assessment of $00.0x per unit sold. Producers of concrete masonry units must complete and return this form within sixty days of the end of each calendar quarter.

Part I: Company information

Company Name: _______________________________________________

Company size (number of employees): __________

Dates covered: __________

Number of concrete masonry unit machine cavities: __________

Number of machine cavities in operation: __________

Amount remitted this quarter: __________

Part II: Manufacturing plant information

If your company has more than one manufacturing plant, you must complete a separate Part II for each plant that has a unique Employer Identification Number (EIN).

Manufacturing Plant Address:

Street _________________________________________________________

State __________________________________________________________

Zip Code _______________________________________________________

Tel #: ( ) _______________________________ E-mail:_________________________________

Employer Identification Number (EIN) ________________

Provide the following for each EIN:

Type	Current quarter			Same quarter last year
	Number produced	Number sold	Amount remitted	Number produced	Number sold
Concrete Block - Gray
Concrete Block – Architectural
Concrete Block – Prefaced
Concrete Block - joined
Concrete Block - Sound wall block
Concrete Block - Fence block
Concrete Block - Lintel Block
Concrete Block - Screen Block
Concrete Block - Chimney, Pilaster, or Column Block
Concrete Block – other (denote type)
Concrete Block – other (denote type)
Concrete Block – other (denote type)
Concrete Brick (Architectural only)
Concrete Masonry Veneer Units (greater than 3 inches in width).
Concrete pavers*
Segmental retaining wall*
Other, non-unit products*

*These products not subject to an assessment.

Part III: Certification

Please check this box if appropriate

□ I am a Manufacturer of Concrete Masonry Products (CMP) and have manufactured CMP within the last 180 days.

USDOC may request documentation to verify your eligibility

__________________________________ ______________________________

Print Name of Company Representative Signature of Company Representative

_____________________________

Date

All information collected will be treated as confidential, as indicated on the forms and in conformance with the Privacy Act and Freedom of Information Act. The Department’s staff is required to maintain confidentiality. Other confidential information will be withheld from public review under the Freedom of Information Act and the Privacy Act, 5 USC 552.

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. This is a new collection and the valid OMB Control Number will be assigned when it is approved. The time required to complete this information 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. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Department of Commerce, Office of the Under Secretary for Economic Affairs at 1401 Constitution Avenue, Washington, D.C. 20230, Attn: Kenneth White, Senior Policy Analyst, or kwhite2@doc.gov.