FGIS 994 Commodity Inspection Certificate (Submitted Sample)

FORM FGIS-994
JAN 07

UNITED STATES DEPARTMENT OF AGRICULTURE

Approved OMB No. 0580-0013

FEDERAL GRAIN INSPECTION SERVICE

AGRICULTURAL MARKETING ACT OF 1946
ORIGINAL

COMMODITY SUBMITTED SAMPLE INSPECTION

US-STFO-1-00098

OFFICIAL PINK CERTIFICATE

LEVEL OF INSPECTION:
Original

ISSUED AT:
STUTTGART, AR

NOT NEGOTIABLE

DATE OF SERVICE:
January 30, 2007

IDENTIFICATION:
BROWN BAG #1234

NOT OFFICIALLY SAMPLED
GRADE AND
COMMODITY:

U. S. No. 1 Long Grain Milled Rice

RESULTS:
Color Creamy
Heat Damage 0
Heat-Damaged Kernels And Objectionable Seeds 0
Milling Degree Well Milled
Other Types 0.0 %
Red Rice And Damaged Kernels 0.3 %
Total Seeds, Heat-Damaged Kernels And Paddy Kernels 0

Chalky Kernels 0.0 %
Objectionable Seeds 0
Moisture 12.7 %
Non-Objectionable Seeds 0
Paddy Kernels 0
Total Broken Kernels 2.3 %
Total Seeds 0

REMARKS:
Applicant states Crop Year 2006.

The sample identification and inspection results shown on this certificate are assigned only to the quantity in the sample and not to any identified carrier, container, or lot from which the sample may have been taken.
I CERTIFY THAT THE SERVICES SPECIFIED ABOVE WERE PERFORMED WITH THE RESULTS STATED.

APPLICANT NAME: Joe Brown
ISSUING OFFICE:

NAME OR SIGNATURE: Diane K Palecek

FGIS - Stuttgart Field Office

This certificate is issued under the authority of the Agricultural Marketing Act of 1946, as amended (7 U.S.C. 1621 et seq.), and the regulations thereunder (7 CFR 868.1 et seq.), and is receivable in all courts of the United States as prima facie
evidence of the truth of the statements therein contained. This certificate does not excuse failure to comply with the provisions of the Federal Food, Drug, and Cosmetic Act, or other Federal Laws.
WARNING: Sec. 203(h) of the Agricultural Marketing Act of 1946 provides that anyone who shall knowingly falsely make, issue, alter, forge, or counterfeit any official certificate, or aid, assist, or be party to such actions, is
subject to a fine of not more than $1000 or imprisonment for not more than 1 year, or both. The conduct of all services and the licensing of personnel under the regulations governing such services shall be accomplished without
discrimination as to race, color, religion, sex, national origin, age, or handicap.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0580-0013. The time
required to disclose this recordkeeping requirement is to average 83.206 hours per recordkeeper annually, including the time to retain such records, and to notify, disclose, and report to third parties such recordkeeping requirements.