FTC-110 FL. Tomatoes Rept. of Spec. Purpose Certificate under Ce

OMB No. 0581-0178

FLORIDA TOMATO COMMITTEE NO. ___________________

800 Trafalgar Court, Suite 300  Maitland, FL 32751

Phone (407) 660-1949  Fax (407) 660-1656 CERTIFICATE OF PRIVILEGE NO.________________

www.floridatomatoes.org

REPORT OF SPECIAL PURPOSE SHIPMENT UNDER CERTIFICATE OF PRIVILEGE

SHIPPED TO: ___________________________________________________________________________________________________________________________________

ADDRESS: _______________________________________________________________________ TELEPHONE: ___________________________________________

Name of Carrier: ___________________________________________________________________ Truck License No. ________________________________________

PURPOSE: □ Pickling □ Canning □ Export □ Charity □ Other _________________________________________________________________

No. of Containers Shipped ______________ Container Wt. ___________________ Maturity _________________ Size ____________ Grade __________________ Date Shipped _________________ Loading Point_________________________ The undersigned Shipper certifies to the Florida Tomato Committee (Committee) and the Secretary of Agriculture that these tomatoes are being shipped in accordance with current Marketing Order regulations for use only for the purpose stated. Falsification of information on this government document may result in a fine, imprisonment, or both (18 U.S.C. 1001). SHIPPER’S NAME ___________________________________________________ Registered Handler No. ____________________ PACA Lic. No. _______________ ADDRESS __________________________________________________________ SIGNATURE ________________________________________________________ Instructions to Shipper: Fill out this report for each Special Purpose Shipment. Sign all four copies. Inspector will mail the original (WHITE) copy to the Committee. Forward the BLUE and YELLOW copies to the receiver. Retain the PINK copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATE.

No. of Containers Received ____________ Container Wt. _____________________ Date Received _________________ Unloading Point _________________________ If used other than stated by Shipper, specify: __________________________________ ______________________________________________________________________ The undersigned Receiver acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above tomatoes will be used for the purpose indicated. Falsification of information on this government document may result in a fine, imprisonment, or both (18 U.S.C. 1001). RECEIVER’S NAME _________________________________________________ ADDRESS __________________________________________________________ SIGNATURE _______________________________________________________ Instructions to Receiver: Upon receipt of these forms, promptly complete the BLUE copy and mail to the Committee. Retain the YELLOW copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES PERMITTING SHIPMENTS OF SPECIAL PURPOSE TOMATOES TO YOUR FIRM.

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.

FTC-110 (Rev. 01/2014. Destroy previous editions.)