F/H Form 1(a) Hazelnuts Free Tonnage Shipments

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823

Fax: (503) 678-6825 DOMESTIC INSHELL SHIPMENTS

Handler ___________________________________ Period _____________________________________

Date of Shipment

Invoice/Lot Number

Inspection Number

Jumbo

Large

Medium

Total

Country

CURRENT YEAR

Total Current Period

Last Period Yr-To-Date

Total Yr-To-Date

Within

0utside

PRIOR YEAR

Production Area

Total Current Period

Last Period Yr-To-Date

Total Yr-To-Date

NOTE: If an export shipment is made where conditions of sale do not meet the Hazelnut Marketing Board requirements, that shipment must be reported as a domestic sale. Please identify all such shipments and note the country the product is exported to in the Country column. If the shipment is made to or through another handler, provide the name of the handler to prevent duplication in reporting shipments.

This report is required by law (7 U.S.C 608(d), 7 CFR 982.66 and 7 CFR 982.466). Failure to report can result in a fine of not less than $50 or more than $5,000 for each such violation and each day during which such violation continues shall be deemed a separate violation.

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 15 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.

F/H Form 1(a) (Rev. 01/2014) Destroy previous editions.