BERRY PRODUCTION AND DISPOSITION INQUIRY ‑ DECEMBER 2013 |
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OMB No. 0535-0039 Approval Expires: 6/30/2013 Project Code: xxx QID: xxxxxx SMetaKey: xxxx |
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NATIONAL AGRICULTURAL STATISTICS SERVICE |
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U.S. Department of Agriculture NOC Division 9700 Page Avenue, Suite 400 St. Louis, MO 63132-1547 Phone: 1-888-424-7828 FAX: 314-595-9990 |
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Please make corrections to name, address and ZIP Code, if necessary.
Information requested in this survey is used to prepare estimates of selected agricultural commodities. Under Title 7 of the U.S. Code and CIPSEA (Public Law 107-347), facts about your operation are kept confidential and used only for statistical purposes in combination with similar reports from other producers. Response is voluntary. 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 0535-0039. The time required to complete this information collection is estimated to average 25 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. |
REPORT FOR THE ACREAGE YOU OPERATE OR MANAGE IN 2013.
(Include acres rented or leased from others. Exclude those rented or leased to someone else.)
1. Please answer the following question(s) for the total acres you (name on label) operate.
D id this operation grow any Blueberries in 2013? Yes (Go to Section 1) No (Continue)
D id this operation grow any Red Raspberries in 2013? Yes (Go to Section 2) No (Continue)
Did this operation grow any Black Raspberries in 2013? Yes (Go to Section 3) No (Continue)
Did this operation grow any Raspberries in 2013? Yes (Go to Section 4) No (Continue)
Did this operation grow any Evergreen Blackberries in 2013? Yes (Go to Section 5) No (Continue)
Did this operation grow any Marion Blackberries in 2013? Yes (Go to Section 6) No (Continue)
Did this operation grow any Other Blackberries in 2013? Yes (Go to Section 7) No (Continue)
(Include Kotata, Chester, Silvan, and others.)
Did this operation grow any Boysenberries in 2013? Yes (Go to Section 8) No (Go to Section 9)
Section 1 – Blueberries
Code |
xxx
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1. Did this operation harvest any cultivated blueberries in 2013? (Exclude wild blueberries)
1 Yes – Continue 3 No – Go to next page
REPORT FOR THE CULTIVATED BLUEBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of cultivated blueberries were on this operation during 2013?. . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of cultivated blueberries, how many acres were harvested during 2013? . . . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of cultivated blueberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . = |
xxx |
___________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Cultivated blueberries reported in items 5a-5e should equal item 4. |
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6. Quantity of mature cultivated blueberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?. . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
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Continue on next page
OFFICE USE |
xxx |
Section 1 – Blueberries (continued)
Code |
xxx
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1. Did this operation harvest any wild blueberries in 2013? (Exclude cultivated blueberries)
1 Yes – Continue 3 No – Go to Section 2
REPORT FOR THE WILD BLUEBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of wild blueberries were on this operation during 2013? . . . . . . . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of wild blueberries, how many acres were harvested during 2013? . . . . . . . . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of wild blueberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . . = |
xxx |
___________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Wild Blueberries reported in items 5a through 5e should equal item 4. |
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6. Quantity of mature wild blueberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?. . . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
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Continue on next page
OFFICE USE |
xxx |
Section 2 – Red Raspberries
Code |
xxx
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1. Did this operation harvest any red raspberries in 2013? (Exclude black raspberries)
1 Yes – Continue 3 No – Go to Section 3
REPORT FOR THE RED RASPBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of red raspberries were on this operation during 2013? . . . . . . . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of red raspberries, how many acres were harvested during 2013?. . . . . . . . . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of red raspberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . = |
xxx |
____________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Red raspberries reported in items 5a through 5e should equal item 4. |
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6. Quantity of mature red raspberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?. . . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
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Continue on next page
OFFICE USE |
xxx |
Section 3 – Black Raspberries
Code |
xxx
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1 Yes – Continue 3 No – Go to Section 4
REPORT FOR THE BLACK RASPBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of black raspberries were on this operation during 2013? . . . . . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of black raspberries, how many acres were harvested during 2013?. . . . . . . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of black raspberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . = |
xxx |
_________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Black raspberries reported in items 5a through 5e should equal item 4. |
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6. Quantity of mature black raspberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?. . . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
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Continue on next page
OFFICE USE |
xxx |
Section 4 –Raspberries
Code |
xxx
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1 Yes – Continue 3 No – Go to Section 5
REPORT FOR THE RASPBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of raspberries were on this operation during 2013? . . . . . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of raspberries, how many acres were harvested during 2013?. . . . . . . . . . . . |
xxx ___ |
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QUANTITY
|
UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of raspberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . = |
xxx |
_________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Raspberries reported in items 5a through 5e should equal item 4. |
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6. Quantity of mature raspberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?. . . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
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Continue on next page
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Section 5– Evergreen Blackberries
Code |
xxx
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1. Did this operation harvest any Evergreen blackberries in 2013? (Exclude other blackberries)
1 Yes – Continue 3 No – Go to Section 6
REPORT FOR THE EVERGREEN BLACKBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of Evergreen blackberries were on this operation during 2013? . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of Evergreen blackberries, how many acres were harvested during 2013? . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of Evergreen blackberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . = |
xxx |
_________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Evergreen blackberries reported in items 5a through 5e should equal item 4. |
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6. Quantity of mature Evergreen blackberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?.. . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
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Continue on next page
OFFICE USE |
xxx |
Section 6 – Marion Blackberries
Code |
xxx
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1 Yes – Continue 3 No – Go to Section 7
REPORT FOR THE MARION BLACKBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of Marion blackberries were on this operation during 2013? . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of Marion blackberries, how many acres were harvested during 2013? . . . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of Marion blackberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . = |
xxx |
__________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Marion blackberries reported in items 5a through 5e should equal item 4. |
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6. Quantity of mature Marion blackberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?.. . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
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Continue on next page
OFFICE USE |
xxx |
Section 7 – Other Blackberries
1. Did this operation harvest any other blackberries in 2013? (Include Kotata, Chester, Silvan, and others.)
Code |
xxx
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1 Yes – Continue 3 No – Go to Section 8
REPORT FOR THE OTHER BLACKBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of other blackberries were on this operation during 2013? . . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of other blackberries, how many acres were harvested during 2013? . . . . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of other blackberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . . = |
xxx |
___________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
|
(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
|
(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
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c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
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d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
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NOTE: Other blackberries reported in items 5a through 5e should equal item 4. |
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6. Quantity of mature other blackberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?.. . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
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Continue on next page
OFFICE USE |
xxx |
Section 8 – Boysenberries
Code |
xxx
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1. Did this operation harvest any boysenberries in 2013?
1 Yes – Continue 3 No – Go to Section 9
REPORT FOR THE BOYSENBERRIES GROWN ON THE LAND YOU OPERATED OR MANAGED IN 2013.
(Include land rented or leased from others. Exclude land rented or leased to someone else.)
2. How many total acres of boysenberries were on this operation during 2013? . . . . . . . . . . . . . . . . . . . . . |
Acres |
xxx ___ |
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3. Of the (item 2) acres of boysenberries, how many acres were harvested during 2013? . . . . . . . . . . . . . |
xxx ___ |
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QUANTITY
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UNIT (Bu, Lbs, Bins, etc) |
POUNDS Per Unit |
AVERAGE PRICE Dollars per Unit |
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4. Quantity of boysenberries harvested for all purposes during 2013? (Include those harvested but not used.) . . . . . . . . . . . . . . . . . . . . . = |
xxx |
_________ |
xxx . __ |
Price at local shipping point after deducting packing and marketing charges |
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5. Of the total quantity reported in item 4, how many were -- |
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a. sold for fresh market as -- |
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|||
(i) bulk sales to packers and truckers? . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
|||
(ii) wholesale? (Include fruit packed by you and sales through co-ops.) + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
|||
(iii) local sales at roadside stands, pick-your-own, and other direct sales to consumers?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
|||
b. sold for commercial processing?. . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
xxx $ ___ ___ |
|||
c. used to make processed items for sale by this operation? + |
xxx |
_________ |
xxx . __ |
|
|||
d. harvested but not sold because of poor quality, marketing restrictions or other reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . + |
xxx |
_________ |
xxx . __ |
|
|||
NOTE: Boysenberries reported in items 5a through 5e should equal item 4. |
|
|
|
||||
6. Quantity of mature boysenberries not harvested because of weather conditions, insect or disease damage, labor shortages, low prices or other economic reasons?.. . . . . . . . . . . . . . . . . . . . . . . . |
xxx |
_________ |
xxx
. __ |
|
|||
|
|
|
Section 9 – Conclusion - COMMENTS about the 2013 berry crop in your locality:
Survey Results: To receive the complete results of this survey on the release date, go to http://www.nass.usda.gov/results
Would you rather have a brief summary mailed to you at a later date? |
099 |
OFFICE USE ONLY |
|
|||||||||||||||
|
Response |
Respondent |
Mode |
Enum. |
Eval. |
Change
785
|
Office Use for POID |
|||||||||
|
1-Comp 2-R 3-Inac 4-Office Hold 5-R – Est 6-Inac – Est 7-Off Hold – Est 8-Known Zero |
9901 |
1-Op/Mgr 2-Sp 3-Acct/Bkpr 4-Partner 9-Oth
|
9902 |
1-Mail 2-Tel 3-Face-to-Face 4-CATI 5-Web 6-E-mail 7-Fax 8-CAPI 19-Other |
9903 |
098 |
100 |
785 |
789
__ __ __ - __ __ __ - __ __ __ |
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|
|
|||||||||||||||
|
R. Unit |
Optional Use |
||||||||||||||
|
921 |
407 |
408 |
9906 |
9916 |
|||||||||||
|
S/E Name |
|
|
|
|
|
|
|||
|
Respondent Name: |
9911
Phone: |
9910 MM DD YY
Date: |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Jeremy Beach |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |