RAC-100C (989) Export Prog. Application for Cash Back

OMB No. 0581-0178

RAISIN ADMINISTRATIVE COMMITTEE

2445 Capitol Street, Suite 200

Fresno, California 93721

Phone: (559) 225-0520

EXPORT PROGRAM APPLICATION FOR CASH BACK

The undersigned Packer hereby requests a cash adjustment payment from the Raisin Administrative Committee (RAC) for the raisins exported pursuant to this application. It is understood that upon submission of all required documents by the packer, the RAC will pay the cash adjustment applicable to the raisins exported pursuant to the Export Replacement Offer in effect as of the date of shipment. This application is subject to all provisions as set forth in the applicable Export Replacement Offer as approved by the RAC and the Secretary of Agriculture (Secretary).

Varietal Type: ___________________________ (specify)

Pack Style	No. per Case				No. of Cases				Packed Weight
Specify weight in pounds					Total Packed Weight
				Natural Condition Weight
			Shrinkage Allowance Total Packed Weight (lbs) ÷
				Cash Back Requested
Country Cash Back Rate								/lb	$
Country
Exporter/Importer
Intended Shipment Date *See Instructions
Packer Reference Number **See Instructions
		Must agree with Reference No. on Truck & Ocean Bills of Lading

The making of any false statement 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 of the United States Code, which provides for a penalty of a fine or imprisonment of not more than five years, or both.

Packer:			FOR RAC USE ONLY
By:
Date:			Date
			Check No.

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 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.

INSTRUCTIONS FOR COMPLETING FORM RAC-100C

No cash adjustment payment will be made by the RAC for free tonnage raisins exported until an application is received from the Packer. (7 U.S.C. 608d, 7 CFR 989.67). The Packer must furnish all information provided for in the form except that specified under “FOR RAC USE ONLY.”

Varietal Type	Use terminology specified in section 989.11 of Marketing Order No. 989, as amended.
Pack Style	Specify the packed configuration of the cases shipped, such as “30 lbs.,” “48/15 oz.,” or “36/125 gm.”
No. per Case	Specify the net fruit weight per case.
No. of Cases	Specify the number of cases applied for as shipped for the specified pack style.
Packed Weight	Multiply the net weight per case (No. per Case) by the number of cases shipped (No. Cases).
Total Packed Weight	Add the computed packed weight for each pack style.
Natural Condition Weight	Divide the Total Packed Weight by the shrinkage factor as specified in the export replacement offer.
“Cash Back” Requested	Multiply the Natural Condition Weight by the “Cash Back” rate as specified in Exhibit A of the applicable Export Replacement Offer.
Country	Specify the final country of destination for this shipment.
Exporter/Importer	Specify the name of the Exporter/Importer to whom the raisins were shipped.
Intended Shipment Date	Specify the date the shipment was made from the packing plant. *Documentation may be required to verify shipments.
Packer Reference No.	Provide a reference number that has been used to identify this shipment. **Documentation may be required to verify quality and/or volume.

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.

RAC-100C (Rev. 01/2017) Destroy previous editions.