CWB Export Form B (984) CA Walnuts Consummation of Sale & Transmittal of S

OMB No. 0581-0178

CALIFORNIA WALNUT BOARD

101 Parkshore Drive, Suite 250 Report No. ______________________

Folsom, CA 95630

Ph (916) 932-7070; Fax (916) 932-7071 Date: ___________________________

CONSUMMATION OF SALE AND TRANSMITTAL OF SUPPORTING DOCUMENTS

In executing this form, the handler respectively certifies to the California Walnut Board (Board) and to the U.S. Department of Agriculture the correctness and completeness of their statement.

We have consummated sale of the reserve walnuts described below at the price recorded and hereby submitted with the required supporting documents:

Unit (Number & Type)	Net Weight (pounds)	Size & Grade	Inspection Certificate No.	Price Per Pound

NAME OF CARRIER ____________________________________ SHIPPING CONTAINER NO. ______________

EXPORTED TO ________________________________________ BROKER _______________________________

(country)

Include the Following Information:

Copy of Invoice to Buyer No. ________________ Signed “On-Board” or“Received for Shipment” No. _____________

Letter of Credit No. ________________________ Issued by:_______________________________________________

(Name of Bank)

Date Paid __________________________, 20___

Cash in Advance:

Date payment received ____________________, 20___

Form of payment:

1. Check No. ___________; Issuing bank __________________________________; Date _______________

2. Bank Draft No. ______________________; Date _____________________________

3. Bank Transfer No. ____________________; Date _____________________________

4. Other - specify ________________________________________________________

The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of title 18, section 1001, United States Code, which provides for the penalty of a fine for individuals and for organizations or imprisonment, or both.

Date Shipped ____________________________________________________________________________________________

Handler _________________________________________________________________________________________________

By _____________________________________________________________________________________________________

Title ___________________________________________________________________________________________________

Note: No credit for reserve disposition for export by the handler in accordance with the export agent agreement can be obtained without first submitting this form to the Board (7CFR 984.56(b), 7CFR 984.456(a)).

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.

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.

CWB Export Form B (Rev. 1/2017) Destroy previous editions.