CDGAC-3 925-CA Desert Grapes End of Season Shipment Rept.

OMB No. 0158-0189

CALIFORNIA DESERT GRAPE ADMINISTRATIVE COMMITTEE

82901 Bliss Avenue

Indio, CA 92201

Phone: (760) 342-4385

Fax: (760) 342-0485

E-Mail: [email protected]

END OF SEASON SHIPMENT REPORT

Handler Address City, State, Zip Code

Grower Address City, State, Zip Code

Reporting Period:

Date of First Shipment to Date of Last Shipment

Please list all grape shipments				Total Number of Lugs Shipped (Pounds)
Invoice Number	Shipping Date	Variety Name	Destination City, State	10 lbs	12 lbs	16 lbs	18 lbs	20 lbs
Totals

The undersigned declares under penalty of perjury that the foregoing is true and correct.

Handler Name Handler Signature Date

The making of a false statement or representation on this form, knowing it to be false, is a violation of Title 18, section 1001 of the United States Code, which provides for a penalty of a fine of $10,000 or imprisonment of not more than five years, or both. This report is required by law. (7 U.S.C. 608(d)) Failure to report can result in a fine of not less than $50 or more than $5,000 for each such violation, and each day during which such violation continues shall be deemed a separate violation.

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. A valid OMB control number for this information collection is 0581-0189. The time required to complete this information collection is estimated to average 30 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 its programs and activities on the basis of race, 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 the 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. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

CDGAC-3 (Rev. 07/10. Destroy previous editions.)