Form SC-24 Positive Lot Identification Stamp/Die Request Form

FORM APPROVED BY OMB No. 0581-0125

UNITED STATES DEPARTMENT OF AGRICULTURE Agricultural Marketing Service Specialty Crops Program

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).

__ Inches

House Number

District Number

Inspection Number

Office/Market Number

___ 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 District Supervisor who will distribute them.

MAIL STAMPS/DIES TO

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

SC-24 (rev. 06-2016)

OMB 0581-0125

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

2. fax: (202) 690-7442; or

3. email: [email protected].

USDA is an equal opportunity provider, employer, and lender.

SC-24 (rev. 06-2016)