CAC 110 905-FL. Citrus Report of Shipments under Certificate of

OMB No. 0581-0189

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 REPACKING CERTIFICATE OF PRIVILEGE

As required by Marketing Order No. 905, regulating the handling of

oranges, grapefruit, tangerines, and tangelos grown in Florida

Shipped to _____________________________________ Address ___________________________

Truck License No. ______________ Shipping Date ___________ Certificate No. ________________

Variety of Citrus Fruit	Number of Containers	Fruit Size	Type of Container	Size of Container	Manifest Number
Total Containers

The undersigned certifies to the Committee and the Secretary of Agriculture that this citrus shipment is being shipped in accordance with current Marketing Order No. 905 Regulations for Repacking. 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.

Repacking Shipper

Address

20___-20___ Season

Repacking Certificate of Privilege No. ________

Signature of Repacking Shipper ______________________________________

Instructions to Repacking Shipper: Complete this report for each repacked shipment. Sign all copies and mail the white copy to the Committee. The pink copy goes with the shipment. Retain the canary copy for your files. Give the goldenrod copy to the trucker.

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 7 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 110 (Rev. 7/10. Destroy previous editions.)