Form FV-24 Positive Lot Identification Stamp/Die Request Form

FORM APPROVED BY OMB No. 0581-0125
UNITED STATES DEPARTMENT OF AGRICULTURE
Agricultural Marketing Service
Fruit and Vegetable Programs
Fresh Products Branch

POSITIVE LOT IDENTIFICATION
STAMP(S)/DIE(S) REQUEST FORM

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 number. The valid OMB number for this information is
0581-0125. The time required to complete this information collection is estimated to average one hour per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining data needed, and
completing and reviewing the collection of information

A. Stamp Description

Stamp Location (Applicant):

Stamp Manufacturer:

Stamp Manufacturer: Please reproduce, at the Applicant’s expense, _______ hand stamps or________ in-line coder printing dies bearing the approved
USDA Federal-State Inspection logo with the following permanently affixed accountability number(s).
District
Number

Inspection
Number

Office/Market
Number

__

Inches

House
Number

___

Inches

B. Applicant’s Request

As a duly authorized agent of the above firm (Applicant), I hereby request that the above stamp/die order be approved and produced. I/We agree to be
responsible for all charges assessed by the stamp manufacturer for this order. I also acknowledge that all stamps/dies ordered are the exclusive property
of the United States Department of Agriculture and/or the___________________________________________________Federal-State Inspection Service.
______________________________________________________
Applicant’s Authorization Signature
E-Mail Address:

___________________________________
Date of Request

C. State/District Authorization

I have reviewed the above request and give approval for the order to be processed.
_______________________________________________________
State/District Authorization Signature

___________________________________
Date of Request

D. Federal Authorization

All stamps/dies which make reference to or imply that a product has been USDA or Federal-State inspected are accountable items and are the property of
the United States Department of Agriculture. No stamps/dies shall be produced without specific written consent of the Federal Program Manager/
Supervisor.
_______________________________________________________
__________________________________
Federal Program Manager / Supervisor’s Signature
Date of Authorization
NOTE:
These stamps/dies are to be
mailed to the Federal-State District
MAIL STAMPS/DIES TO
Supervisor who will distribute
them.
E. Manufacturer’s Statement

I certify that each stamp/die produced by this firm bears a permanent accountability number and the only stamps/dies produced by this firm with markings
referencing the USDA and/or the ______________________Federal-State Inspection Service are those that have been authorized in writing by the USDA.
________________________________________
______________________________________
_________________________________
Manufacturer’s Signature of Compliance
Title
Date of Shipment
F. Local/District Receipt

I have received_______________ (quantity) stamp/dies bearing the following permanently affixed accountability number(s).
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
__________________________________________________________
District Supervisor’s Signature

___________________________________________________________
Date Received

G. Authorized PIQ-PLIDS Firm Representative/Inspector’s Receipt

I have received the above listed stamps/dies and they are now my responsibility.
__________________________________________________________________

Authorized Signature

___________________________________________________________________

Date Received

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.

FV-24 (9/06) Previous editions may be used.