F/H Form 4 Hazelnuts Declaration of Inshell Hazelnuts

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823

Fax: (503) 678-6825

DECLARATION OF INSHELL HAZELNUTS

The undersigned handler hereby designates that as of _____________________, 20____, the following lots of certified inshell hazelnuts are to be considered as handled on the domestic market by the Hazelnut Marketing Board (Board) and subject to such restricted obligation as may accrue from such handling:

Pounds Size Location

Date ________________________________ HANDLER ___________________________________

By __________________________________________

Title _________________________________________

Shipments from the above are to be reported at the end of the month shipped.

No handler may elect to have the certified merchantable hazelnuts, which have not been handled at the end of a marketing policy year, bear the restricted and assessment obligations of that year or of the marketing policy year in which handled unless a completed declaration is made to the Board (7 U.S.C. 608(d), 7 CFR 982.50,7 CFR 982.450).

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 20 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.

F/H Form 4 (Rev. 10/2010) Destroy previous editions.