Form FV-266-5 920-Kiwifruit Return Receipt to Growers

OMB No. 0581-0189

RETURN RECEIPT OF KIWIFRUIT TO GROWER

TO: Kiwifruit Administrative Committee

1521 “I” Street

Sacramento, CA 95814

Phone: (916) 441-0678

Fax: (916) 446-1063 Email: [email protected]

This form is used to verify provisions of the Marketing Order and to serve as proof of fruit ownership when transporting/selling fruit. Keep the original of this form on file, mail or fax a copy to the Committee office, and give a copy to the grower.

LEGAL OWNER (Grower's Name)
Address
City/State/Zip
Telephone Number

Type of Container
Number of Containers
Approximate Total Pounds
Container Markings

Fruit Picked Up From (check one):

Packer___ Handler___ Shipper___ Cold Storage___

Name of Firm Where Fruit Picked Up From
Address
City/State/Zip
Telephone Number

Signature of Grower_______________________________________ Date: _________

Signature of Firm Owner or Employee_______________________________ Date: _________

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 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.

FV-266-5 (Rev. 9/10. Destroy previous editions.)