CIAB 6 Grower Diversion Application & Tart Cherry Orchard Map

OMB No. 0581-0177

CHERRY INDUSTRY ADMINISTRATIVE BOARD

GROWER DIVERSION APPLICATION

Crop Year 20   

To divert cherries in your orchard for Crop Year 20__, this form must be filed at the CIAB office no later than April 15, 20 .    Along with this application, new and/or updated orchard maps for the diverted blocks must also be submitted.

Name of Grower:        Grower #:

Address:

City:          State          Zip

Phone number: ( )     

This section must be completed.    (Indicate all appropriate responses.)

1. I have carefully reviewed the orchard maps sent to me by CIAB after January 20__ and there are NO changes to any of those blocks represented by those printouts.    I certify those printouts are a true and accurate representation of my current orchard blocks.   

2. Attached are __________ _ revised orchard maps.    The rest are the same

C.    Attached are _                                new orchard maps.   

      (Number of maps)

I agree by participating in this diversion program that I will abide by the rules and regulations hereby established by the Board for diversion.

Authorization for Limited Sharing of Information

B y marking this box I authorize the CIAB and the various state statistical services, including the Michigan, New York, Oregon, Pennsylvania, Utah and Wisconsin Agricultural Statistic Services, to share information regarding the layout, location and composition of my tart cherry orchards.    I recognize that this sharing of information will streamline the reporting of this information to both the CIAB and the statistical services.    This authorization shall continue for the next 5 years unless it is revoked by me in writing.

Signature:    Dated:

Return by April 15, 20_____    to:

Cherry Industry Administrative Board

12800 Escanaba Drive, Suite A

P.O. Box 388

DeWitt, MI 48820-0388

Phone: (517) 669-1070      Toll Free: (888) 639-2422

Fax: (517) 669-1260

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 0581-0177. The time required to complete this information collection is estimated to average 10 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.

Cherry Industry Administrative Board

TART CHERRY ORCHARD MAP

GROWER NAME: CIAB #:							PHONE:
ADDRESS: CITY:               STATE: ZIP:
BLOCK NAME: BLOCK #:							COUNTY:
Township: __________Section #: __________ T: _____ R: _____ S: _____(Example: T2N, R1W, S12) GPS Info, Optional and if Available Lat. Long. Row 1, Tree 1 ___    ___’    ___” / ___    ___’    ___” Point 2 ___    ___’    ___” / ___    ___’    ___” Point 3 ___    ___’    ___” / ___    ___’    ___” Point 4 ___    ___’    ___” / ___    ___’    ___” Point 5 ___    ___’    ___” / ___    ___’    ___” Point 6 ___    ___’    ___” / ___    ___’    ___” Point 7 ___    ___’    ___” / ___    ___’    ___” Point 8 ___    ___’    ___” / ___    ___’    ___” BLOCK LOCATION: (Provide available info.)
NEAREST CROSSROADS:    ____________________                                       and __________________________ LOCATION DIRECTIONS:
GENERAL INFORMATION ABOUT THIS BLOCK OF CHERRIES
ACRES:      ____ . __            SPACING: ___  x ___  EST. OF LIVE TREES REMAINING: ___ __ %					VARIETY:     Montmorency     Balaton Meteor (optional)     Other
ROW NO. 1 IS ON THE        North              South            East            West      SIDE OF THE FIELD.
PLEASE NOTE: PLEASE MAP THE BLOCK AS IT WAS ORIGINALLY PLANTED.
ROW NO.	TREES IN ROW	YEAR PLANTED	ROW NO.	TREES IN ROW		YEAR PLANTED		ROW NO.	TREES IN ROW	YEAR PLANTED
1			21					41
2			22					42
3			23					43
4			24					44
5			25					45
6			26					46
7			27					47
8			28					48
9			29					49
10			30					50
11			31					51
12			32					52
13			33					53
14			34					54
15			35					55
16			36					56
17			37					57
18			38					58
19			39					59
20			40					60

IF THE BLOCK IS LARGER THAN 60 ROWS, USE ANOTHER MAP FOR THE CONTINUATION AND INDICATE THAT THE SECOND MAP IS A CONTINUATION OF THE FIRST.    ATTACH OR DRAW MAP(S) THAT SHOWS BLOCK LOCATION USING SECTIONS, TOWNS, ROADS, and/or OTHER IMPORTANT LANDMARKS SO THAT THE BLOCK CAN BE EASILY FOUND.     

I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT MAPPING OF THE ORCHARD TO WHICH IT APPLIES.

Grower Signature          Date:   

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.

CIAB 6 Grower Diversion Application (Rev. 12/2016)