CAC 201 905- Citrus Grown in FL Report of Special Purpose Shipme

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE

P.O. Box 24508

Lakeland, FL 33802-4508

Phone: (863) 682-3103

Fax: (863) 683-9563

Email: [email protected]

REPORT OF SPECIAL PURPOSE SHIPMENT OF CERTIFIED ORGANIC CITRUS

UNDER CERTIFICATE OF PRIVILEGE

Shipped to

Address ___________________________________________ State _______ Zip Code ______________

Carrier’s Name _________________ Truck License No. ______________ Shipping Date ____________

Number of Cartons Shipped (4/5 Bu. Boxes):

Oranges:

Grapefruit:

Tangelos/ Temples:

Tangerines:

Total:

Inspection Certificate No. ____________________________________ Season _____________________

Certified Groves Supplying Citrus Fruit for this Shipment

Grove Certification Number

INSTRUCTIONS TO SPECIAL PURPOSE SHIPPER

Complete this report for each special purpose shipment. Sign all copies; mail the original (white) copy to the Citrus Administrative Committee; forward the pink copy with the shipment; and retain the yellow copy for your files. This report must be returned within ten (10) days.

FAILURE TO COMPLY WILL RESULT IN

CANCELLATION OF CERTIFICATE OF PRIVILEGE

I (we) certify to the Citrus Administrative Committee and the Secretary of Agriculture that this fruit is shipped in accordance with current Marketing Order No. 905 regulations for use only for the purpose stated. I (we) realize that the making of a false statement, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statutes, which provide for fine and imprisonment.

Shipper Name ________________________________ Special Purpose Shipper Number: ________

Authorized Signature 20___-20___ Season

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 OMB 0581-0189. 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.

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.

CAC Form 201 (Rev. 9/2016. Destroy previous editions.)