No Form Number Texas Citrus Certificate of Privilege

OMB No. 0581-0189

TEXAS VALLEY CITRUS COMMITTEE

901 Business Park Drive, Suite 400

Mission, Texas 78572

Telephone: (956) 581-2190

Fax: (956) 584-3307

CERTIFICATE OF PRIVILEGE NO. __________

I, the undersigned, hereby certify to the Secretary of Agriculture and to the Texas Valley Citrus Committee that I have read, fully understand, and will comply with, the foregoing rules that govern the handling of citrus for processing or for manufacturing for conversion into specified by-products, relief or charity. I further understand that noncompliance is a violation of the Agricultural Marketing Agreement Act, and is subject to a fine of up to $1,100 for each violation.

By: ______________________________ ___________________________ ____________

Name (please print) Signature Date

Firm Name: ___________________________________ Title:____________________________

Address:

Mailing Address, City, State, and Zip Code

Physical Address (if different than mailing address): __________________________________________

Phone: _______________________________ Fax: __________________________________

Person in charge of Special Purpose forms:

Purpose of Shipments:  Processing  Relief/Charity  Otherwise Diverted ______________

(check applicable boxes)

Where will shipments originate?

List Names and Addresses of Consignees below:

APPROVED BY: ______________________________________ 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.

Rev. 09/13. Destroy previous editions.