Form FV-6 Importer's Exempt Commodity Form

OMB APPROVED. 0581.0167

16408

SERIAL NO.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

IMPORTER'S EXEMPT COMMODITY FORM (FV-6)
The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995. The authority for requesting
the information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937. The provisions of criminal and civil fraud statutes, including 18
USC 286, 287, 371, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to information provided on this form.

NOTE: This form is used to declare intent to import an agricultural commodity exempt from grade requirements for the commodity
established under section 8e of the Agricultural Marketing Agreement Act of 1937.

WARNING: Any person who knowingly shall falsely make, issue, alter, forge, or counterfeit this form, or participate in any such
actions, is subject to a fine or imprisonment for not more than five (5) years, or both.

THIS FORM MAY NOT BE DUPLICATED

This e-certificate was created by the MOAB on-line Services
http://www.ams.usda.gov/fv/8eOnline.html

SECTION TO BE COMPLETED BY THE IMPORTER
2. DATE AND PLACE OF INSPECTION (If applicable)

1.PRODUCT (include variety)

Tomatoes, Other
3. LOT IDENTIFICATION

4. VEHICLE IDENTIFICATION (Railroad car, truck, vessel, carrier, tag number, etc.)

5a. IMPORTER'S NAME AND COMPLETE MAILING ADDRESS (P.O. Box, Street, City, State, ZIP Code)

6a. PLACE OF ENTRY/PORT OF UNLOADING

Rick's Soup Co

3106

1234 Main Street
Anytown PA 12345

6b. DATE OF ENTRY

Aug 23 2011

5b. TELEPHONE NUMBER (Include area code)

5c. FAX NUMBER (Include area code)

7. TOTAL QUANTITY IMPORTED (Pounds)

45000

222-555-1212
8a. RECEIVER'S NAME AND COMPLETE MAILING ADDRESS (P.O. Box, Street, City, State, ZIP Code)

9. INTENDED USE (Mark an "X" in appropriate box)

Test Receiver
111 1st Avenue
Tucumcari AZ 54321

X

8b. TELEPHONE NUMBER (Include area code)

Processing

Charity

Livestock/
Animal Feed

8c. FAX NUMBER (Include area code)

Type processing/other (Specify)

999-888-9090
10a. U.S. CUSTOMS SERVICE ENTRY NUMBER

12345678901

10b. HARMONIZED TARIFF CODE NUMBER

0702002045

CERTIFICATION STATEMENT: I certify to the U.S. Department of Agriculture and the U.S. Customs Service that the above is true and accurate

and that none of the fruit, vegetable, or specialty crops being imported and which are identified above will be used for other than the purposes
indicated above.
DATE

TITLE

SIGNATURE (Handwritten only)

President

Aug 23 2011

SECTION II TO BE COMPLETED BY THE RECEIVER
RECEIVER'S NAME AND COMPLETE MAILING ADDRESS (P.O. Box, Street, City, State, ZIP Code)

TELEPHONE NUMBER (Include area code)

CERTIFICATION STATEMENT OF PROCESSOR, CHARITY, FEEDER, OR OTHER EXEMPT RECEIVER

I hereby certify to the U.S. Department of Agriculture that I have received the exempt commodity ahipment(s) cited above and that I will dispose of
the shipment(s) pursuant to the intended use specified in "9" and the commodity's Import Regulations under 7 CFR, Parts 944, 980, or 999, and
that I am one of the following: (Mark an "X" in appropriate box)
Processor

Charity

Livestock/Animal Feeder

SIGNATURE (Handwritten only)

FV-6 (06-99)

(Previous edition of 7-98 may be used)

TITLE

Other (Specify)
DATE