CWB 4 & 5 CA. Walnuts - Inventory Report

California Walnut Board
101 Parkshore Drive, Suite 250
Folsom, CA 95630
Ph (916) 932-7070 Fax (916) 932-7071

OMB NO. 0581-0178
CWB Form #4 & #5
Due Date: __________, 20__

INVENTORY REPORT
This inventory report is submitted in compliance with the requirements of the Federal Marketing Order No. 984, as amended. In
executing this form, the handler respectively certifies to the California Walnut Board and to the U.S. Department of Agriculture as to
the correctness and completeness of their statement.

Instructions
Section 1 (this page):
1. Report certified inshell and shelled inventory as indicated (product that you, as the handler, own)
2. Report uncertified inventory that will be inspected and sold as inshell by inshell weight and report inshell and
shelled inventory that will be inspected and sold as shelled by kernel weight (product that you, as the handler,
own)
3. If you are not holding any inventory, write “NONE” on the form.

Section 2 (next page):
1. If you are holding inventory for another party, including but not limited to, a grower, another handler, or an
exporter for custom packing or storage (product NOT owned by you), please complete Section 2 on the next
page.
2. Please report certified and uncertified shelled and inshell inventory held in pounds and list the name, address
and phone number of the party that owns the product.
3. Please use an additional sheet if you need more space.
Mail a signed original to the California Walnut Board (CWB) office on or before ________________, 20___.

1. WALNUT INVENTORY – HANDLER-OWNED PRODUCT
Inshell Pounds

Shelled Pounds

Certified Walnuts:
Uncertified Walnuts:

TOTAL

Handler: _______________________________________________________________________________
Signature: _____________________________________________________________________________
Print Name:___________________________________________________________________________
Title: _____________________________________________ Date: ______________________________
The making of any false statements or representations 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, United States Code, which provides for the penalty of a
fine of $250,000 for individuals and $500,000 for organizations or imprisonment of not more than five years, or both.

OMB NO. 0581-0178
CWB Form #4 & #5
Due Date: Sept. 15, 2013

Handler Name:__________________________________________________________
2. WALNUT INVENTORY – HELD FOR THIRD PARTIES (list each separately)
Inshell Pounds

Shelled Pounds

Product owned by:
Name:

Certified Walnuts:

Address:

Uncertified Walnuts:

City/State/ZIP:

Total:

Phone:
Email:
Inshell Pounds

Shelled Pounds

Product owned by:
Name:

Certified Walnuts:

Address:

Uncertified Walnuts:

City/State/ZIP:

Total:

Phone:
Email:
Inshell Pounds
Certified Walnuts:
Uncertified Walnuts:
Total:

Shelled Pounds

Product owned by:
Name:
Address:
City/State/ZIP:
Phone:
Email:

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 10 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.