CAC-402 (905) FL. Citrus--Shipments under Grower Tree Run Certif

OMB No. 0581-0189

Shipment No. ____________________

CITRUS ADMINISTRATIVE COMMITTEE

P.O. Box 24508

Lakeland, FL 33802-4508

Phone: (863) 682-3103

Fax: (863) 683-9563

[email protected]

REPORT OF SHIPMENTS UNDER GROWER TREE RUN CERTIFICATE

Variety of Citrus	Legal Description of Grove	1-3/5 Bu. Boxes Equivalent
	Total 1-3/5 Bushel Boxes

Truck/Trailer License No. ___________________________________ Shipping Date ______________

The undersigned certifies to the Citrus Administrative Committee (Committee) and the Secretary of Agriculture that this citrus shipment is being shipped in accordance with current Marketing Order No. 905 regulations. I (we) 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.

Grower___________________________________________ Grower Tree Run Certificate No. _____

Address

Signature of Grower

Instructions to Grower: Complete this report for each shipment. Sign all copies, and return the white copy to the Committee. The yellow copy stays with the shipment, and the pink copy is retained by the Road Guard Station. Retain the gold copy for your files.

NOTE: 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 0581-0189. 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 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 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.

CAC Form 402 (Rev. 7/10. Destroy previous editions.)