CAC 201 905- Citrus Grown in FL Report of Special Purpose Shipme

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 SPECIAL PURPOSE SHIPMENT OF CERTIFIED ORGANIC CITRUS
UNDER CERTIFICATE OF PRIVILEGE
Shipped to __________________________________________________________________________
Address ___________________________________________ State _______ Zip Code ______________
Carrier’s Name _________________ Truck License No. ______________ Shipping Date ____________
Number of Cartons Shipped (4/5 Bu. Boxes):
Tangelos/
Oranges:
Grapefruit:
Temples:

Tangerines:

Total:

Inspection Certificate No. ____________________________________ Season _____________________
Certified Groves Supplying Citrus Fruit for this Shipment
Grove Certification Number ____________________________________________________________
INSTRUCTIONS TO SPECIAL PURPOSE SHIPPER
Complete this report for each special purpose shipment. Sign all copies; mail the original (white) copy to
the Citrus Administrative Committee; forward the pink copy with the shipment; and retain the yellow
copy for your files. This report must be returned within ten (10) days.
FAILURE TO COMPLY WILL RESULT IN
CANCELLATION OF CERTIFICATE OF PRIVILEGE
I (we) certify to the Citrus Administrative Committee and the Secretary of Agriculture that this fruit is
shipped in accordance with current Marketing Order No. 905 regulations for use only for the purpose
stated. 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.
Shipper Name ________________________________ Special Purpose Shipper Number: ________
Authorized Signature
20___-20___ Season

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CAC Form 201 (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
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.

CAC Form 201 (Rev. 12/2018. Destroy previous editions.)