CAC 110 905-FL. Citrus Report of Shipments under Certificate of

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE
PO Box 941058
Maitland, FL 32794
Phone: (321)-214-5252 or (407) 765-5940
[email protected]
REPORT OF SHIPMENTS UNDER REPACKING CERTIFICATE OF PRIVILEGE
As required by Marketing Order No. 905, regulating the handling of
oranges, grapefruit, tangerines, and tangelos grown in Florida
Shipped to _____________________________________ Address _______________________________
Truck License No. _________________ Shipping Date ___________ Certificate No. ________________
Variety of
Citrus Fruit

Number of
Containers

Fruit Size

Type of
Container

Size of
Container

Manifest
Number

Total
Containers
The undersigned certifies to the Committee and the Secretary of Agriculture that this citrus shipment is
being shipped in accordance with current Marketing Order No. 905 Regulations for Repacking. 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.
Repacking Shipper ____________________________________________________________________
Address _____________________________________________________________________________
20___-20___ Season
Repacking Certificate of Privilege No. ________
Signature of Repacking Shipper ______________________________________
Instructions to Repacking Shipper: Complete this report for each repacked shipment. Sign all copies
and mail the white copy to the Committee. The pink copy goes with the shipment. Retain the canary
copy for your files. Give the goldenrod copy to the trucker.

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 0581-0189. The
time required to complete this information collection is estimated to average 7 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.

CAC Form 110 (Rev. 12/2018. Destroy previous editions.)

OMB No. 0581-0189

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
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Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American
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To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
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CAC Form 110 (Rev. 12/2018. Destroy previous editions.)