RAC-166 Uncashed or Unclaimed Claim Affirmation Form

OMB No. 0581-0178

RAISIN ADMINISTRATIVE COMMITTEE

2445 Capitol Street, Suite 200

Fresno, California 93721

Phone: (559) 225-0520

UNCASHED OR UNCLAIMED GROWER CHECK

CLAIM AFFIRMATION FORM

The undersigned claimant certifies, under penalty of perjury, that the claimant is the person entitled to receive the funds for the non-cashed grower check referenced below. The claimant has provided evidence that the check owner produced raisins in the reserve pool year indicated. The claimant agrees to indemnify and hold harmless the United States Department of Agriculture (USDA) and its agents, the Raisin Administrative Committee (RAC), and its officers and employees, from any loss resulting from the payment of said claim.

CURRENT INFORMATION AND SIGNATURE MUST BE PROVIDED FOR EACH CLAIMANT. Use an additional form or attach a sheet with other claimant(s) information and signature(s).

Claimant Information

LAST NAME OR BUSINESS		FIRST NAME				MIDDLE INITIAL		SSN OR TAX ID NO.
MAILING ADDRESS				CITY				STATE			ZIP CODE
DAYTIME PHONE	CLAIMANT OR AUTHORIZED AGENT SIGNATURE1										DATE
1For claims filed for a business, the authorized owner’s signature is required. For claims filed for an estate or trust, the signature of the executor, administrator or attorney is required.
Uncashed or Unclaimed Grower Check Claimed
CHECK OWNER NAME AND ADDRESS AS ISSUED		DATE ISSUED				CHECK NO.				AMOUNT
		RESERVE POOL YEAR
RAC USE ONLY
RAC Authorization							Date
Re-Issued Check Information
CLAIMANT NAME AND ADDRESS AS ISSUED			DATE ISSUED				CHECK NO.		AMOUNT

INSTRUCTIONS FOR FILING A CLAIM

Using this instruction sheet, determine and provide the appropriate documents in order to process your claim, and return them with your completed Claim Affirmation Form. All claimants must review SECTION A for required documentation. If you are an heir or beneficiary of the deceased owner, refer to SECTIONS A and B. If you are a business claimant, refer to SECTIONS A and C.

SECTION A:   CLAIMANT IDENTIFICATION

1. Provide a copy of a photo identification (e.g., driver’s license, state identification card, passport, etc.) for each claimant; and

2. Provide a copy of each claimant’s Social Security card or any other document showing the claimant’s Social Security number (e.g., federal or state income tax return, pay stub, etc.); and

3. Do you have any documents (e.g., photo identification in item 1 above, utility bill, tax bill, bank statement, or other correspondence, etc.) indicating that you or the owner currently reside or once resided at the “Address as Issued” indicated on the front page of the Claim Form?

4. Provide a Delivery Report from a packer or other documents to evidence that the check owner produced raisins in the reserve pool year, the amount of raisins delivered and the packer to whom the raisins were delivered.

5. NOTE: IF MISSING ITEMS 3 OR 4, YOUR CLAIM MAY BE DENIED.

SECTION B:   DECEASED OWNER

If you are an heir of the deceased owner named on the check, you are required to submit ALL items under SECTION A, the death certificate of the deceased owner, AND one of the following documents:

1. A copy of Currently Certified Letters, dated within the past six months, appointing the Executor or Administrator of the decedent’s estate, and the Estate Tax Identification number; or

2. A complete copy of the Court Ordered Distribution of the Decedent’s Estate; or

3. If the distribution of the estate was not ordered by a court, a complete copy of the decedent’s Will and/or Trust Agreement, and a completed Declaration Under Probate Code Section 13101 form; or

4. If no Will or Trust Agreement exists, a completed Declaration Under Probate Code Section 13101 form and a Table of Heirship form. You may obtain these forms from our office.

SECTION C:   BUSINESS

In addition to the items in SECTION A, provide items 1 through 4 below, as well as either item 5 or item 6:

1. A copy of the business card of an authorized officer or official; and

2. A Letter of Authorization on company letterhead with the names of the officers or officials with authority to sign and claim on behalf of the business; and

3. Proof of the business’s current Federal Tax Identification Number; and

4. Proof of the business’s association with the last known address.

Also provide:

5. A copy of the Merger Agreement if the company has merged with another company; or

6. A copy of the Articles of Dissolution if the company has been dissolved.

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended.  The authority for requesting the information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674).  Furnishing the requested information is necessary for the administration of the marketing order program.  Submission of the Tax Identification Number (TIN) is mandatory, and will be used to validate ballots and determine affiliation or entity identity.  Please note that ballots will not become invalid if a TIN is not disclosed.

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 0581-0256. The time required to complete this information collection is estimated to average 6 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, SW, Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

RAC-166 (01/2014)