No Form number So. TX Onions Relief or Charity Certification for Handli

OMB No. 0581-0178

SOUTH TEXAS ONION COMMITTEE

901 Business Park Drive, Suite 500, Mission, TX 78572

Phone: (956) 584-9331 Fax: (956) 584-0300

RELIEF OR CHARITY CERTIFICATION

FOR HANDLING ONIONS WHICH FAIL TO MEET

THE SOUTH TEXAS ONION RULES AND REGULATIONS

Effective Date: __________ Expiration Date: ________________

No shipments of special purpose onions may be made unless this form is completed and returned to the South Texas Onion Committee (Committee) (7 CFR 959.126). Two (2) copies of this Certification are enclosed. If you receive onions which do not meet the South Texas Onion Rules and Regulations, from South Texas Onion Handlers, to be used for charitable and relief purposes, you must complete this certification and return one copy to the Committee office, retaining the other copy for your files.

It is understood and agreed to by me, the undersigned applicant, that all onions granted a Certificate of Privilege for Special Purpose Shipments, by virtue of this application and corresponding Special Purpose Shipment Reports, must be used for the purpose stated in this application and any deviation or infringement of this privilege which shall become known to me will be reported to the Committee promptly. Further, I will not knowingly sell or cause to be sold onions which have been granted a Certificate of Privilege and are to be used in violation of Certificate. I acknowledge that making of a false or fraudulent statement for the purpose of influencing the actions of a government agency shall, upon conviction, be subject to a fine or imprisonment, or both (18 U.S.C. 1001).

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Print Name Signature

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Firm Name Title

_________________________ ___________________________ _____________________

Telephone Number Fax Number Date

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Street or Box Number, City, State, and Zip Code

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Physical address if different than above mailing address

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 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. 01/2014. Destroy previous editions.