RAC-100C Export Program Application for Cash Back

RAC - 100C			EXPORT PROGRAM APPLICATION FOR CASH BACK					Office of Management & Budget
Revised 4/09			RAISIN ADMINISTRATIVE COMMITTEE					OMB No. 0581-0178
			P.O. Box 5217
			Fresno, CA 93755-5217
	The undersigned Packer hereby requests a cash adjustment payment from the RAISIN ADMINISTRATIVE
	COMMITTEE for the raisins exported pursuant to this application. It is understood that upon submission of all required
	documents by the packer, the Raisin Administrative Committee will pay the cash adjustment applicable to the raisins
	exported pursuant to the Export Replacement Offer in effect as of the date of shipment. This application is subject
	to all provisions as set forth in the applicable EXPORT REPLACEMENT OFFER as approved by the RAISIN
	ADMINISTRATIVE COMMITTEE and the SECRETARY.
	VARIETAL TYPE: NATURALS
			Pack Style		# Per Case	No. Cases	Packed Weight
			TOTAL PACKED WEIGHT
			NATURAL CONDITION WEIGHT
				SHRINKAGE ALLOWANCE
				TOTAL PACKED WEIGHT				LBS.
			CASH BACK REQUESTED :
				COUNTRY CASH BACK RATE:__________/LB
				COUNTRY:
				EXPORT / IMPORTER:
SHIPMENT DATE/RAC 21 MONTH & REPORT NUMBER
PACKER REFERENCE NO./USDA CERTIFICATE NUMBER OR MEMO REPORT OF INSPECTION NUMBER
					(Must agree with Reference No. on Truck & Ocean Bills of Lading)
	The making of any false statement or representations in any matter within the jurisdiction of any agency of the
	United States, knowing it to be false, is a violation of Title 18, Section 1001, United States Code, which provides
	for a penalty of a fine of $10,000 or imprisonment of not more than five years, or both.
	PACKER:					By:	Date:
	FOR RAC use only:				DATE:		Check No.