FV-212 915-Avocados Report of Special Purpose Shipment

Generic OMB Fruit Crops, Marketing Order Administration Branch

FV-212 Report of Special Purpose Shipment (09-13)

Generic Fruit Crops (Mandatory)

OMB: 0581-0189

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REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAM

REPORT OF SPECIAL PURPOSE SHIPMENT

UNDER CERTIFICATE OF PRIVILEGE

Avocado Administrative Committee

P.O. Box 900188

Homestead, FL 33090-0188

Tel: (305) 247-0848

SHIPPED TO


ADDRESS (City, County, State, and Zip Code)


NAME OF CARRIER


TRUCK LICENSE NUMBER

PURPOSE: Seed Charity (fresh) Processing

NUMBERS OF CONTAINERS SHIPPED


CONTAINER WEIGHT

NUMBER OF CONTAINERS RECEIVED

CONTAINER WEIGHT

DATE SHIPPED


LOADING POINT

DATE RECEIVED

UNLOADING POINT

CERTIFICATION STATEMENT: The undersigned certifies to the Committee and the Secretary of Agriculture that these avocados are being shipped in accordance with current Marketing Order Regulations for use only for the purpose stated. I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment.

If used other than stated by Shipper, specify:


CERTIFICATION STATEMENT: The undersigned acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above avocados will be used for the purpose indicated. I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment.

NAME OF SHIPPER


REGISTERED HANDLER NUMBER (if applicable)


PACA LICENSE NUMBER (if applicable)


NAME OF RECEIVER


ADDRESS (City, County, State, and Zip Code)


ADDRESS (City, County, State, and Zip Code)



SIGNATURE OF SHIPPER


SIGNATURE OF RECIEVER

SHIPPER INSTRUCTIONS: Fill out this report for each Special Purpose Shipment. Sign all four (4) copies. Mail the original (white) copy to the Committee. Forward the yellow and pink copies to the receiver. Retain the gold copy for your files. FAILURE TO COMPLY CONSTITUTES A VIOLATION OF MARKETING ORDER NO. 915.

RECEIVER INSTRUCTIONS: Upon receipt of these forms, promptly complete the pink copy and mail to the Committee. Retain the yellow copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES PERMITTING SHIPMENTS OF SPECIAL PURPOSE AVOCADOS TO YOUR FIRM.





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 0581-0189. The time required to complete this information collection is estimated to average 6 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.

FV-212 (Rev. 9/13. Destroy previous editions.)

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