No Form number Annual Allotment Certificate, Class 3

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ANNUAL ALLOTMENTCERTIFICATE
CLASS3
--------------------------------------------OMS #0581-0178

DATE
_ '_ '_
N
A
T
I
V
E

By
Name of HANDLERor,
if DEFICIENCY,Other GROWER

Signeture of Hendler
or CommitteeAgenl

The matingor a 'alse certification,knowingII 10 ba 'alse, III an agencyof the U.S. Is a vlolallon of Tille 18, Seellon1001, or Ihe U.S. CodewhIch
pnwIdesfor a penaII1III naI mOIl!tII;n $10,000or imjlisonmenlof noIl1IO/Bthan
WIITE

-

COntmilllle

rears,or tJoIh.

-

ance YELLOW A1I8ch

10 Purd1ase

.

Voucher PINK Handler

Balance

--------------------------------------------OMS #0581-0178

DATE
_ ,_ ,_
N
A
T
I
V
E

By

Nameof HANDLER
or,
if DEFICIENCY,
OtherGROWER

Signature of Handler
or CommitteeAgent

The mating of a fllse 1XII1iIcaID1,
knowing1\" be fils., 1011\agency or1IIeu.s. Is a vlDIaIIonIII Tille 18, SecIcI1 1001, of 1IIe U.s. Code 8IicII
pI'IIWides for a penaltyof not more 11111I
$10,000or Imprtsonmeat01 not _
lIIan fire years, or boIII.
WIITE

. Coaunlllee 0IIIce

YEUOW. A1Iachb PI.Rbase Voucher

PIlI(

---------------------------------------------

-

Handler

Belence

OMS #0581-0178

_ '_'_

DATE

N
A
T
I
V
E

By

Name of HANDLERor,
If DEFICIENCY,Other GROWER

Signature of Handler
or CommitteeAgenl

The llal:ng or a false C8IGIIcaIbI,
~
PIOYIdes

~ b be false, ID111agencyoIeIIe 118. Is a violationof Tile 18, SecIIon 1001, llllIIe U.S. Code wh~
Ibr a penally III nOl more II1Ia1$10.000 or Imprisclnmenl of not more than eve years, or both.

-

WHITE Comlll\lee 0IIIce YEllOW

-AIIach b

Pun:IIase VaodIet

PN(

. Handler

Balance

--------------------------------------------OM8 #0581-0178
DATE

N
A
T
I
V
E

_ 1_ '_

By

Name of HANDLERor,
II DEFICIENCY,Other GROWER

Signature of Handler
or CommitteeAgent

The maIcIng d a false C8ItIIIcation.knowing it b be false. 10 .. agency of !he U.s. Is a vIo1aIIonof Tile 18. SecIIon 1001. d !he U.8. Code whIc:h
pro'11d8sfor a penaII1 or not mDf8 II1an .10.000 01 Implaonllent or nol more 1Iran 'we years, or both.
WHIR:

- CommltlBe

0IIice

YEU.OW

-Allach 10 PIadIase

Voucher

PIIIK

-

HantWer

Balance

--------------------------------------------OMB#0581..o178

DATE

N
A
T
I
V
E

_ '_ '_

By
Name of HANDLERor,
If DEFICIENCY,Other GROWER

Signature of Handler
or CommitteeAgenl

Tha mailing d a false C*I1IcaIlon. knowingit 10 be false, ID an agency of lie U.S. 1$ a wicQIionor TI1Ie18, section 1001, of lie U.S. Code whldJ
pI'IIWides
for a penaIIJof not more 11.. .10,000 or IlI1prisonme!t
or not more lhan five }'I!81S,or both.

.

.

WIITE . COnImIII8t0IIce YEllOW

---------------------------------------------

-

AIIach

III Pwt:Irase

Voucher

PINK

.

Handler

Balance

CLASS THREE BASE CERTIFICATE
FAR WEST SPEARMINT OIL ADMINISTRATIVE

COMMITTEE

The CLASS THREE (NATIVE) BASE as of

Is Established At

Ibs.

for

Effective

According to the Paperworlf ReductIon Act of 1995. an agency may not conduct or sponsor. and a person Is not required 10
t8spond to a collection of Information unless It displfIYS a valid OMB conlTol number. The valid OMB conlTol number for this
Infonrtatlon ~lectIon Is 0581-41178. The time required to complete this Information collection Is estimated to awrage ten
minutes per response, including the time for reviewing instroctions. searching existing date sources. gathering and maintaining
the data naeded, and complotlng and reviowlng tho collection of information.
The U.S. Depattment of Agriculture (USDA) prohibits di6criminationin all its programs and activitieson the ba$i$ of race. color;
national origin, age, disability, and where applicable. sex, marital status,familial status, parental status, religion, sexual
orientation, genetic In/ormation, poIJtIcBl beliefs. reprtss1, or because a" or pstt of BlI IndMdual's
Income Is dertved from any
public assl~
program(Not all prohibited bases apply to all programs.) Persons with dlsabHltJe8who require alternative
means for communk:atfon of program Infonnation (BtaiIJe.Istge print, aucflOtspe, etc.) should contact USDA:' TARGET Center at
(202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA. Director, Office of Civl1Rights, 1400
IndependenceAvenue, S.W:, Washington,D.C. 20250-9410,or call (800)795-3272(voice)or (202) 720-6382(TDD).USDA Is an
equal oppottunityprovider and employer.