WMB 20 Report of Substandard Walnuts Delivered

OMB NO. 0581-0178
WMB Form #20

Walnut Marketing Board
1540 RIver Park Drive, Suite 203
Sacramento CA 95815-4609
Ph (916) 922-5888 Fax (916) 923-2548

REPORT OF SUBSTANDARD WALNUTS DELIVERED
This report of substandard walnuts delivered Is submitted Incompliance withthe requirements ofthe Federal MarketingOrder No.
984, as amended. In executing this form, the Handler respectively certifies to the Walnut Marketing Board and to the U.S.
Department of Agriculture as to the correctness and completeness of their statement

Instructions:

1.
2.
3.

Alldeliveries must be made to Approved Substandard Users.
Complete the Informationbelow.
Mail a copy of the form to the Walnut Marketing Board (WMB)followingeach delivery.
Substandard Users will complete WMB Form #24-15, Report of Substandard Walnuts
Received. The WMBwillmatch the forms to verifydlsDOsitionof substandSrd walnuts.

DFA Inspection Certificate
Number (If applicable)

Kernel %

KInd & Number
of Containers

Lot No.

Net Weight

The above kemelweight of walnuts was delivered to:
Name of Approved User:
Delivery Date:
Delivered By:

Handler:
By:

Title:

IF AVAILABLE, ATTACH WEIGHMASTER CERTIFICATE FOR EACH LOT
The making of any false statements or representations Inany matter withinthe Jurisdiction of any agency of
the United States, knowing It to be falS8,Is a violation of Title 18, Section 1001,United States Code, which
provides for the penalty of a fine of $250,000for Individualsand $500,000for organizations or Imprisonmentof
not more than five years, or both.
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 058 1-0178. The
time required to complete this information collection is estimated to average 5 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 ofrace, 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 alternativemeans for communication of program information (Braille, large print, audiotape, etc.)
should contact USDA's TARGET Center at (202) 720-2600 (voice and TOD). To file a complaintof 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.