PMC 8.443 CA Dried Prunes Claim for Reserve Pool Proceeds

Form PMC 8.443
OMS 0581-0178

CLAIM FOR RESERVE ~OOL PROCEEDS
To:

I.

Date

Prune Marketing Committee
3841 North Freeway Blvd., Suitel20
Sacramento, CA 95834
CLAIM:

Claim is hereby made by the undersigned for reserve pool proceeds on prunes delivered under the name and address of
, as follows:

Handler

Crop Year

II.

BASIS OF CLAIM:

Amount

Date

Quantity

The basis of this claim is marked with an X; below:

(

) The prunes were owned by me (us).

(

) The proceeds were assigned to me (us).

(

) My leasehold share is

%. The r.emainder belongs to:

Address

Name

Percent

(

CheckNo.

) I was appointed administrator or executor of estate of payee, now deceased, on
20-,
by
in Probate Case No.

(Name and Address of Court)

(

) I am (we are) the sale surviving heir (s) of payee, deceased; no other persons are entitled to share in these proceeds,

(

) Other

- as follows:

III. INDEMNIFICATION:
In consideration of remittance to the undersigned of the pool proceeds shown above, I (we) hereby
agree to hold and keep the Prune Marketing Committee harmless from and indemnified against any liability or loss arising there from
or any claim or demand by any other person claiming such proceeds.
(Claimant's Signature)

(Mailing Address)

(Claimant's Signature)

(Mailing Address)

INSTRUCTlo.NS:
This fonn .mu~ be comple~, signed by all claimants, and submitted to the Prune Marketing Committee together with all
doc~ments ~ecessary to substantiate It, such as assl~ents:
.leases, certified. copies of letters of administration, court orders, affidavits of right to
rece!ve moOl~ due a deceased person. orders for the dIsposItion of estates without administration, or other legal documents evidencing authority to
receIve the claImed proceeds. These documents will be promptly examined and returned.
IMPORTANT NOTICE
aI f fi f
The issuanceof a falsecertificateknowingit to be falseis a violationofTide 18 Section1001of the UnitedStatesCode which
.d
than S I0,000 or imprisonment of not more than S years or both.'

,

pravi es a pen ty 0 a IDe0 not more

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