F/H Form C(2) Hazelnuts Form for Justification of Sureties

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823

Fax: (503) 678-6825

FORM FOR JUSTIFICATION OF SURETIES

STATE OF _________________________)

) ss.

COUNTY OF _______________________)

__________________________________________________________, a surety whose name is subscribed to the above undertaking, being duly sworn, says that he is one of the sureties named in the forgoing undertaking and is worth the sum specified in said undertaking as the maximum total aggregate liability thereunder, over and above all his just debts and liabilities, exclusive of property exempt from execution, and that he is a resident of ____________________________, County of __________________________, State of _____________________.

_____________________________________________

Subscribed and sworn to before me

this ______ day of _______________, 20____.

_____________________________________

Notary Public for ____________________

My commission expires _________________

STATE OF ________________________)

) ss.

COUNTY OF ______________________)

________________________________________________________, a surety whose name is subscribed to the above undertaking, being duly sworn, says that he is one of the sureties named in the forgoing undertaking and is worth the sum specified in said undertaking as the maximum total aggregate liability thereunder, over and above all his just debts and liabilities, exclusive of property exempt from execution, and that he is a resident of ____________________________, County of __________________________, State of _____________________.

_____________________________________________

Subscribed and sworn to before me

this ______ day of ___________, 20____.

_____________________________________

Notary Public for ____________________

My commission expires _________________

No deferment of restricted obligation will be granted through bonds with sureties acceptable to the Board unless a form for justification of sureties is completed and received by the Board (7 U.S.C 608(d), 7 CFR 982.54 and 7 CFR 982.454).

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 30 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.

F/H Form C(2) (Rev. 01/2014) Destroy previous editions.