PMC 8.443 CA Dried Prunes Claim for Reserve Pool Proceeds

OMB No. 0581-0178

CLAIM FOR RESERVE POOL PROCEEDS

To: Prune Marketing Committee Date _________________________, 20___

3840 Rosin Court, Suite 170

Sacramento, CA 95834

1. CLAIM: Claim is hereby made by the undersigned for reserve pool proceeds on prunes delivered under the name and address of _______________________________________________________________, as follows:

Crop Year	Handler	Amount	Check No.	Date	Quantity

II. BASIS OF CLAIM: The basis of this claim is marked with an X; below:

• The prunes were owned by me/us.

• The proceeds were assigned to me/us.

• My leasehold share is _________ %. The remainder belongs to:

Percent	Name	Address

• I was appointed administrator or executor of estate of payee, now deceased, on ______, 20__, by ____________________________________________ (Name and Address of Court) in Probate Case No. _______________________________.

• I am (we are) the sole surviving heir(s) of payee, deceased; no other persons are entitled to share in these proceeds,

• Other -as follows: ________________________________________________________________

III. INDEMNIFICATION: In consideration of remittance to the undersigned of the pool proceeds shown above, I (we) hereby agree to hold and keep the Prune Marketing Committee (Committee) harmless from and indemnified against any liability or loss arising there from or any claim or demand by any other person claiming such proceeds.

________________________________________________________________________________________________________

(Claimant’s Signature) (Mailing Address)

________________________________________________________________________________________________________

(Claimant’s Signature) (Mailing Address)

IMPORTANT NOTICE: The issuance of a false certificate knowing it to be false is a violation of title 18 section 1001 of the United States Code, which provides a penalty or imprisonment, or both.

INSTRUCTIONS: This form must be completed, signed by all claimants, and submitted to the Committee together with all documents necessary to substantiate it, such as assignments, leases, certified copies of letters of administration, court orders, affidavits of right to receive monies due a deceased person, orders for the disposition of estates without administration, or other legal documents evidencing authority to receive the claimed proceeds. These documents will be promptly examined and returned.

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.

PMC 8.443 (Rev. 01/2014. Destroy previous editions.)