FV-231-1A PACA License Reinstatement Notice

PACA LICENSE REINSTATEMENT

NOTICE

INSTRUCTIONS: If all of the information SHOWN ON THE FRONT OF THIS FORM is current and complete, "X" the "With NO Change" box below OR if the information is NOT current or correct,
"X" the "With CHANGE(s)" box and report the appropriate changes or additions in the spaces below. This form must be signed and returned completed, with the total REINSTATEMENT FEES
DUE to be received by the anniversary date. Under "Nature of Business" check the ONE BOX which represents the predominant style of your operations.
If there have been changes in ownership,
partners. officers, directors, members and/or managers of LLCs or holders of more than 10 percent of the stock, or in their address, you should include and/or update ALL information requested
for each individual. Missing or incorrect data on the front of this form may be inserted there. Adding and deleting persons should be reported in the space provided below. If license is NOT
being renewed, explain your reason under "REMARKS"andreturn this form. QUESTIONS???call (202) 720-3053.
FRUITS AND VEGETABLES HANDLED
("X" one box) (Item 3 on front)
1.0

Fresh

2. 0

Frozen

3.0

NATURE OF BUSINESS ("X" one box) (Item 4 on front)
Both

4.

0

5. 0

Wholesaler

6.0

Commission Merchant

Retailer 8. 0

7. 0

Broker

Processor 9. 0

Trucker O. 0

Foo~ G.0
Service

Grocery
Wholesaler

CHANGES IN OWNERSHIP, PARTNERS,OFFICERS,DIRECTORS, MEMBERS AND OR MANAGERS OF LLCs AND HOLDERSOF MORE THAN 10% OF THE STOCK (If there have been any changes,
"X. the box showing your current operations.)
CHANGES (X)
Add

DATE OF
CHANGE

Delete

SOCIAL SECURITY
NUMBER

LEGAL NAME

(Last - First - Midd/e /nitial)

FULL HOME ADDRESS
(Street and Number, City, State, and ZIP Code)

DIRECTORl
TITLE
X

% OF
STOCK

.
REPORTEDOWNERSHIP(Item 5 on front) HAS CHANGED TO:

D

("X. one box)
CHANGES (X)
Add

("X"

D

I

-=

o

Individual

DATE

C = Corp.

o

A = Assoc.

OF

T

-

Trust

o

E

-

Estate

o

L

-

Limited

Partnership

o

o

M = Company

TRADE NAME (d/b/a) OR BRANCH

CHANGE

Delete

o

DATE OF CHANGE

Limited
Liability

one box)

Signature

D

With NO change

P = Partnership.No.
Partners........

LOCATION

and Title of Owner,

(City, State, and ZIP Code)

SIGNATURE

Partner,

Member/Manager (LLC) or Officer

With CHANGE(s) shown above

TITLE

Making Application for License Renewal

REMARKS

RETURN APPLICATION

AND FEES TO:

TO PAY BY CREDIT CARD:

0

VISA

USDA-AMS-P ACA

0

AMERICAN

P.O. BOX 790327

0

DINERS CLUB

ST LOUIS, MO 63179-0327

ACCT. NO.

MAKE CHECKS

PAYABLE

D

MASTERCARD

D

DISCOVER

TO "USDA-AMS"

Please include license number being renewed on check.

(For more information

EXPRESS

about P ACA, visit our

II
NAME OF CARD HOLDER SIGNATURE (Please Print)

Accordingto the Paperwork ReductionAct of 1995. an agency may not conduct or sponsor,
and . person is not required to respond to . coUectionof informationunless h: displays. valid
OMS control number. The valid OMS control number for this information collection is
0581.()()31. The time required to comptelethis informattancollectionis estimated to average
3 minutes per response, includingthe time for reviewinginstructions, searching existing data
sources. gathering and maintaining the data needed. and completing and reviewing the
collectionof information.

AMOUNT

$
MO
EXPIRATION
DATE

VR

The U.S. Department of Agriculture«USDA)prohibits discriminationin aU its programs and
activities on the basis of r.ce, color, national origin,gender, religion,age. disability. political
beliefs. sexual orientation. and marit.1or family statuI. (Notall prohibitedbasel apply to all
programs.) Persons with disabilities who require alternative me.ns for communication of
programinformation(Braille.largeprint,audiotape.etc.) shouldcont.ct USDA's TARGET
Center.t 202-720-2600
(voice
andTOO). To file a complaintof discrimination.write USDA.
OirectOf',Officeof CivilRights. Room 326-W. Whinen Building.1400 Independence Avenue.
SW.Washington.
DC 20250-9410or call (202) 72()'59641voice and TOOl. USDAis an eQu.1
opportuntiyproviderand employer.

website: "www.ams.usda.gov/fv/paca.htm".)
FV-231-1A

(01-051

tl

u.s. GPO:2005-716-116

Form Approved. - OMS No. 0581 . 0031
According to the Paperwork Reduction
valid OMS control number. The valid
this information collection is estimated
data sources, gathering and maintaining

PACA LICENSE
REIN"STATEMENT
NOTICE
Your PACA license expires on anniversary date shown
below as the annual fees were not paid. The license may
be reinstated by paying the annual fee plus a $50
.........."'''"L..............Lfee within 30 davs of the anniversarY d w
t. LICENSE

NO.

2. ANNIVERSARY
DATE

11-27-2006

19910266

BUS:

Phone:

N 400

LAKE

VILLAGE

9800

N 400

LAKE

VILLAGE

The U.S. Department of Agriculture (USDA) prohibits discrimination in its programs on the basis afrace, color, national origin, gender,
religion, age, disability, political beliefs, sexual orientation. and marital or family status. (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 TOD). To tile a complaint of discrimination, write USDA, Director,
office of Civil Rights, Room 326-W, Whinen Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410or call (202)
720~5964 (voice and TOO). USDA is an equal opportunity provider and employer

3. TYPE OF BUSINESS

4. NATURE OF BUSINESS

FRESH FRUITS & VEG

COATES FARM PRODUCE
9800

Act of 1995, no persons are required to respond to a collection ofinfonnation unless it displays a
OMB control numb.:r for this information collection is 0581-0031. The time required to complete
to average 3 minutes per response, including the time for reviewing instructions, searching existing
the data needed. and completing and reviewing the collection information.

S. OWNERSHIP

WHOLESALE DEALER

TYPE

6. NO. OF
BRANCHES

CORPORATION

0

NOTICE TO LICENSEE
THIS IS A BILL. Failureto return this Formand
fee within 30 days will result in the terminationofyour
PACA license. COMPLETE REVERSE SIDE

INC

E

IN

RENEWAL FEES

46349-9249

E

IN

46349-9249

BASIC

$

BRANCH

$

550.00
.00

REINSTATE

$

50.QO......
..

FEES DUE

$

600.00

MUTI YEAR OPTIONS
("X" one box)

(219) 345-3217

I

Fax:

I

Email:

STATE IN WHICH INCORPORATED
FORMED

EIN:

12

YEARRENEWALFEESDUES

1,150.00

n3

YEARRENEWALFEESDUES

1.700.00

OR

INDIANA
PRINCIPALS
NAME (LAST

DATE

INCORPORATED 01-01-1990

-OWNER. PARTNERS. OFFICERS. DIRECTORS. MEMBERS. AND HOLDERS OF MORE THAN 10% OF STOCK
- FIRST - MIDDLE INITIAL\
- -

SOCIALSEC. NO.

HOME ADDRESS

TITLE

COATES DAVID A
LAKE VILLAGE

IN

LAKE VILLAGE

IN

COATES DORIS D

-

50.00

S

50.00

NOTICE TO LICENSEE You are licensed under the Perishable Agricultural Commodities Act as described above. (fyou are continuing in business,
subject to the Act, you must renew the license for another year. This renewal application must be signed on the reverse and must reach this office by the
anniversary date shown above. See reverse for Instructions on how to report changes in your business operations, if any have occurred. PENALTIES:
Operations without a license could result in an injunction plus a civil penalty of $1200 for each offense plus $350 for each day the offense continues.
FV-231-IA
Return form wilh fees 10: USDA PACA Branch
Make check payable to USDA-AMS
(10-02)
P.O.BOX790327
CG:IIFDL
St. Louis MO 63179 - 0327

-

% OF STOCK

PD