CAC Form 110

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CITRUS ADMINISTRATIVE COMMITTEE
P.O. Box 24508
Lakeland, FL  33802-4508
Phone: (863) 682-3103
Fax: (863) 683-9563
[email protected]

REPORT OF SPECIAL PURPOSE SHIPMENT OF CERTIFIED ORGANIC CITRUS
UNDER CERTIFICATE OF PRIVILEGE

Shipped to 	

Address ___________________________________________ State _______ Zip Code ______________

Carrier’s Name _________________ Truck License No. ______________ Shipping Date ____________

Number of Cartons Shipped (4/5 Bu. Boxes):
Oranges:

Grapefruit:

Tangelos/
Temples:

Tangerines:

Total:


Inspection Certificate No. ____________________________________ Season _____________________

Certified Groves Supplying Citrus Fruit for this Shipment
Grove Certification Number 	

INSTRUCTIONS TO SPECIAL PURPOSE SHIPPER
Complete this report for each special purpose shipment.  Sign all copies; mail the original (white) copy to the Citrus Administrative Committee; forward the pink copy with the shipment; and retain the yellow copy for your files.  This report must be returned within ten (10) days.

FAILURE TO COMPLY WILL RESULT IN 
CANCELLATION OF CERTIFICATE OF PRIVILEGE

I (we) certify to the Citrus Administrative Committee and the Secretary of Agriculture that this fruit is shipped in accordance with current Marketing Order No. 905 regulations for use only for the purpose stated.  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.

Shipper Name ________________________________	Special Purpose Shipper Number: ________
Authorized Signature			20___-20___ Season

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.