No Form number So. TX Onions Rept. of Special Purpose Onion Shipment

OMB No. 0581-0178

SOUTH TEXAS ONION COMMITTEE

901 Business Park Drive, Suite 500 Mission, TX 78572

Phone: (956) 584-9331 Fax: (956) 584-0300

REPORT OF SPECIAL PURPOSE ONION SHIPMENT

Handler Certificate of Privilege No. ____________________________ Date __________________, 20___

Receiver _____________________________________________________________________________________

Address ______________________________________________________________________________________

Truck No. __________________________________ Trailer No. ________________________________

 Canning or Freezing

_________________________________________  Relief or Charity

Print Carrier’s Name  Other ___________________________________

Carrier’s Signature ________________________________________________________________________

Carrier’s signature acknowledges this shipment cannot be diverted to any other receiver without contacting the handler.

Quantity: __________________________________________ Total Pounds

(ATTACH WEIGHT TICKET)

The undersigned certifies that these onions are in compliance with the regulations of Marketing Order No. 959 for Onions Grown in South Texas.

Handler Name _________________________________________________________________________________

Signature _____________________________________________________________________________________

TO BE COMPLETED BY RECEIVER

Quantity Received ______________________________________________________________________________

The undersigned acknowledges receipt of and certifies that the above onions will be diverted from fresh channels in accordance with the regulations of the South Texas Onion Committee.

__________________________________________ ________________________________________

Receiving Organization Authorized Representative

ORIGINAL (white copy) must be promptly mailed to the South Texas Onion Committee (Committee). DUPLICATE (canary copy) and TRIPLICATE (pink copy) shall be given to party receiving the onions. Upon arrival at destination, the party transporting the onions shall give both copies to the party actually receiving the onions, whereupon said party shall insert the quantity of onions received, sign and promptly mail the CANARY copy to the Committee. The TRIPLICATE (pink copy) may be retained by the receiver. QUADRUPLICATE (gold copy) may be retained by Handler authorizing the movement of onions from source.

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 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. 10/2010. Destroy previous editions.