FV-24 Positive Lot Identification Stamp/Die Request Form

	FORM APPROVED BY OMB No. 0581-0125
SPECIALTY CROPS INSPECTION DIVISION POSITIVE LOT IDENTIFICATION STAMP(S)/DIE(S) REQUEST FORM
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 number. The valid OMB number for this information is 0581-0125. The time required to complete this information collection is estimated to average 1 hour per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information.

A. Stamp Description

Stamp Location (Applicant):

Stamp Manufacturer:

Stamp Manufacturer: Please reproduce, at the Applicant’s expense, _______ hand stamps or _______ in-line coder printing dies bearing the approved USDA Federal-State Inspection logo with the following permanently affixed accountability number(s).

House Number

District Number

Inspection Number

Office/Market Number

___ Inches

___ Inches

B. Applicant’s Request

As a duly authorized agent of the above firm (Applicant), I hereby request that the above stamp/die order be approved and produced. I/We agree to be responsible for all charges assessed by the stamp manufacturer for this order. I also acknowledge that all stamps/dies ordered are the exclusive property of the United States Department of Agriculture and/or the _________________________________________ Federal-State Inspection Service.

_________________________________________________ ______________________________

Applicant’s Authorization Signature Date of Request

E-Mail Address:

C. State/District Authorization

I have reviewed the above request and give approval for the order to be processed.

________________________________________________ ______________________________

State/District Authorization Signature Date of Request

D. Federal Authorization
All stamps/dies which make reference to or imply that a product has been USDA or Federal-State inspected are accountable items and are the property of the United States Department of Agriculture. No stamps/dies shall be produced without specific written consent of the Federal Program Manager/Supervisor. ________________________________________________ ______________________________ Federal Program Manager/Supervisor’s Signature Date of Authorization
NOTE:	These stamps/dies are to be mailed to the Federal-State		Mail Stamps/Dies to:
	District Supervisor who will distribute them.

E. Manufacturer’s Statement

I certify that each stamp/die produced by this firm bears a permanent accountability number and the only stamps/dies produced by this firm with markings referencing the USDA and/or the ______________________ Federal-State Inspection Service are those that have been authorized in writing by the USDA.

________________________________________________ ___________________________________ ______________________________

Manufacturer’s Signature of Compliance Title Date of Shipment

F. Local/District Receipt

I have received _______________ (quantity) stamp/dies bearing the following permanently affixed accountability number(s).

____________ ____________ ____________ ____________ ____________ ____________ ____________

____________ ____________ ____________ ____________ ____________ ____________ ____________

________________________________________________ ______________________________

District Supervisor’s Signature Date Received

G. Authorized PIQ-PLIDS Firm Representative/Inspector’s Receipt

I have received the above listed stamps/dies and they are now my responsibility.

________________________________________________ ______________________________

Authorized Signature Date Received

FV-24 (9/14) Destroy previous editions. USDA is an equal opportunity provider and employer.