CDAC-2 CA Dates--Report of Exempt Sales

OMB No. 0581-0178

Send one signed copy to:

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

REPORT OF EXEMPT SALES

___________________________________________ located at _________________________________________

Selling Handler

Address

does hereby notify the California Date Administrative Committee (Committee) of a transfer of the dates described below to:

___________________________________________ located at _________________________________________

Buying Handler

Address

on _________________________________________.

Date

Variety	Directly to consumers at my own roadside stand or date shop	Directly to consumers shipped by parcel post or express	Other (under handler exemption specified on my application
	State in terms of pounds of whole dates
Deglet Noor
Halawy
Khadrawy
Zahidi
Total Pounds (lbs)

I hereby certify to the U.S. Department of Agriculture and to the Committee that the information contained in this report is complete and accurate.

Handler or Producer: ____________________________________ By: ________________________________

Signature: _____________________________________ Date: _______________________________

Title: _________________________________________

The making of false statement or representation on this form, knowing it to be false, is a violation of title 18 section 1000 of the United States Code, which provides for the penalty of a fine or imprisonment, or both. This report is required by law (7 USC 608(d), 7 CFR 987.51, 987.151). Failure to report can result in a fine for each violation and each day during which such violation continues shall be deemed a separate violation.

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 30 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 of 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, political beliefs, genetic information, 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.

CDAC-2 (Rev. 10/2010) Destroy previous editions.