No Form Number Orange & Grapefruit Diversion Report

OMB No. 0581-0189

TEXAS VALLEY CITRUS COMMITTEE

No. __________________

901 Business Park Drive, Suite 400
Mission, Texas 78572
Telephone: (956) 581-2190
Fax: (956) 584-3307
ORANGE AND GRAPEFRUIT DIVERSION REPORT
Issued under authority of Certificate of Privilege No. ______________

Date _______________________

Receiver: _____________________________________________________________________________________
Name of approved processor, charitable organization, relief, or otherwise
Address _____________________________________________________________________________________
Truck Lic.: _____
Trailer Lic.: ______
Inspection Cert. No.: ______
R.R. Car Initial & No.: ______
Quantity (Total Lbs. Net Actual or
Estimate)
Grapefruit
Charity/Relief
Oranges
Otherwise Diverted Grapefruit
Oranges

_______Grapefruit

________Oranges

Containers
Containers
Containers
Containers

Total Lbs. Net
Total Lbs. Net
Total Lbs. Net
Total Lbs. Net

The undersigned certifies that these oranges or grapefruit are diverted from fresh fruit channels in accordance with
the regulations of the Texas Valley Citrus Committee (the “Committee”).
______________________________________
Handler

_______________________________________
Authorized Representative

TO BE FILLED IN BY RECEIVER:
Quantity received: ________________ Grapefruit

_________________ Oranges

The undersigned acknowledges receipt of the above fruit, and certifies that it will be diverted from fresh channels in
accordance with the Committee regulations.
________________________________________
Receiving Organization

______________________________
Authorized Representative

The making of any false statements or representation in any matter within the jurisdiction of any agency of the United States,
knowing it to be false, is a violation of Title 18, section 1001 of the United States Code, which provides for a penalty of a fine of
$10,000, or imprisonment of not more than five years, or both.
INSTRUCTIONS: Mail the white (original) copy of this form to the Committee. The canary (duplicate) and pink (triplicate)
copies must be given to the party receiving the fruit. Upon arrival at the destination, the party transporting the fruit must give
both copies to the party actually receiving the fruit, whereupon said party must insert the net weight of the fruit received, sign,
and promptly mail the canary copy to the Committee. The pink copy may be retained by the manufacturer for filing purposes.
The gold (quadruplicate) copy may be retained for filing purposes by the Handler authorizing movement of this fruit.
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. 7/10. Destroy previous editions.