No Form Number Certificate of Privilege

OMB No. 0581-0189

TEXAS VALLEY CITRUS COMMITTEE
901 Business Park Drive, Suite 400
Mission, Texas 78572
Telephone: (956) 581-2190
Fax: (956) 584-3307
CERTIFICATE OF PRIVILEGE NO. __________
I, the undersigned, hereby certify to the Secretary of Agriculture and to the Texas Valley Citrus
Committee that I have read, fully understand, and will comply with, the foregoing rules that govern the
handling of citrus for processing or for manufacturing for conversion into specified by-products, relief or
charity. I further understand that noncompliance is a violation of the Agricultural Marketing Agreement
Act, and is subject to a fine of up to $1,100 for each violation.
By: ______________________________
Name (please print)

___________________________
Signature

Firm Name: ___________________________________

____________
Date

Title:____________________________

Address: ____________________________________________________________________________
Mailing Address, City, State, and Zip Code
Physical Address (if different than mailing address): __________________________________________
Phone: _______________________________

Fax: __________________________________

Person in charge of Special Purpose forms: _________________________________________________
Purpose of Shipments:

Processing

Relief/Charity

Otherwise Diverted ______________

(check applicable boxes)

Where will shipments originate? _________________________________________________________
List Names and Addresses of Consignees below:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
APPROVED BY: ______________________________________

DATE:____________________

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 05810189. 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.

Rev. 07/12. Destroy previous editions.