Organic Exemption request Form

Persons that produce and market only products eligible to be labeled as "100 percent organic" may request exemption from 

assessment under research and promotion programs. The information on this form is required to make a determination 

 concerning a person's eligibility for exemption.

Type of Operation: Insert appropriate program operations. See supplemental list. (Boards that assess only one

 type of operation may omit this section.)

Please complete the following:

Company name:

Street Address:

City/State/Zip code:

Phone:

Fax:

E-mail (optional):

In order to be exempt, the above-named company must meet all of the following (please check):

Operates under an approved organic system plan authorized by the National Organic Program 

(NOP) (7 CFR Part 205) 

Produces/handles/imports/exports/processes only products eligible for a 100% organic label 

under the NOP 

Is not a split operation as defined by the Organic Foods Production Act of 1990

Please list all commodities produced /handled /imported /exported /processed 

(Use continuation sheet if necessary):

Commodity Eligible to be labeled as 

100% Organic? Commodity Eligible to be labeled as 100% Organic?

A copy of this company's organic farm or organic handling operation certificate provided by 

a USDA-accredited certifying agent must be attached. Importers should attach a copy of 

this certificate from each person from whom they receive products. (Boards that do not

asses importers may delete the second sentence.)

Certification Statement

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

Signature Title Date

Please return this form to:

AMS-15 (03-08) See reverse for burden/non-discrimination statement

OMB No. 0581-0093

Y

Y

Y

Y

Y

Y

N

N

N

N

N

N
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. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of 

race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political 

 beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with 

disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720- 

2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or 

call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. 

AMS-15 (03-08) (Reverse)
0581-0217 

AMS-15 Supplemental List

Type of Operation Selections:

Producer Handler First Handler Processor Importer Exporter

Seed Stock Producer Feeder
If you need more space to list commodities, please use this sheet.

Continuation Sheet for AMS-15 

Organic Exemption Request Form

Company Name:

In order to exempt, the above-named company must meet all of the following (please check):

Operates under an approved organic system plan authorized by the National Organic Program 

(NOP) (7 CFR Part 205) 

Produces/handles/imports/exports/processes only products eligible for a 100% organic label 

under the NOP 

Is not a split operation as defined by the Organic Foods Production Act of 1990

Commodity Commodity

Eligible to be labeled as 

100% Organic?

Eligible to be labeled as 

100% Organic?

OMB No. 0581-0093

Y N

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

N

N

N

N

N

N

N

N

N

N