FTC-110 FL. Tomatoes Rept. of Spec. Purpose Certificate under Ce

FLORIDA TOMATO COMMITTEE
Administering Marketing Order No. 966
FORM
FTC-110

Certificate of
Privilege No.
800 Trafalgar Court, Maitland, Florida 32751
Telephone: (407) 660-1949
REPORT OF SPECIAL PURPOSE SIllPMENT UNDER CERTIFICATE OF PRIVILEGE

SIllPPED TO:
ADDRESS:

TELEPHONE: (

Name of Carrier:

Truck License No.

PURPOSE: Pickling

Canning

No. of Containers Shipped

Container Wt.

Maturity
Date Shipped

Size

Export

Grade
Loading Point

The 1U1dersigned Shipper certifies to the Committee and the Secretary of Agriculture that these
tomatoes are being shipped in accordance with current Marketing Order Regulations for use only
for the pmpose stated I realize that the making of a false statement, knowing it to be false, is a
violation of Title 18, Section 1001, of the United States Code, among other statutes, which
provide for fine and imprisonment.
SHIPPER'S NAME
Registered Handler No.

PACA Lie. No.

ADDRESS _
SIGNATURE
Instructions to Shipper: Fill out this report for each Special Pmpose Shipment. Sign all four
copies. Inspector will mail the original (WHITE) copy to the Committee Office. Forward the
BLUE and YELLOW copies to the receiver. Retain the PINK copy for your files. FAILURE
TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATE.

)

Charity

No. of Containers Received
Date Received

Other

Container Wt
Unloading Point

If used other than stated by Shipper, specify:

The 1U1dersignedReceiver acknowledges receipt of and certifies to the Committee and the
Secretary of Agriculture that the above tomatoes will be used for the purpose indicated. I realize
that the making of a false statement, knowing it to be false, is a violation of Title 18, Section
1001, of the United States Code, among other statutes, which provide for fme and imprisonment.
RECEIVER'S NAME

_

ADDRESS

SIGNATURE

Instructionsto Receiver: Uponreceiptof these forms,promptlycompletethe BLUE copy and
mail to the Committee Office. Retain the YELLOW copy for your files. FAILURE TO
COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES PERMITIING
SHIPMENTS OF SPECIAL PURPOSE TOMATOES TO YOUR FIRM.

Note: The following statements are made in accordance with the Privacy Act of 1974 (5 US.c. 552a) and the Paperwork Reduction Act of 1995. The
authority for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19,48 Stat. 31, as
amended, (7 US.C. 601-674). Furnishing the requested information is necessary for the administration of the marketing order program.
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 0581-0178. 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 US. 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 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. 202509410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.