CDGAC-3 925-CA Desert Grapes End of Season Shipment Rept.

OMB No. 0581-0189

CALIFORNIA DESERT GRAPE ADMINISTRATIVE COMMITTEE

82901 Bliss Avenue

Indio, CA 92201

Phone: (760) 342-4385

Fax: (760) 342-0485

Email: [email protected]

END-OF-SEASON SHIPMENT REPORT

Handler Address City, State, Zip Code

Grower Address City, State, Zip Code

Reporting Period:

Date of First Shipment to Date of Last Shipment

Please list all grape shipments				Total Number of Lugs Shipped (Pounds)
Invoice Number	Shipping Date	Variety Name	Destination City, State	10 lbs	12 lbs	16 lbs	18 lbs	20 lbs
Totals

The undersigned declares under penalty of perjury that the foregoing is true and correct.

Handler Name Handler Signature Date

The making of a false statement or representation on this form, 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, or both. This report is required by law. (7 U.S.C. 608(d)) Failure to report can result in a fine for each such violation, and each day during which such violation continues shall be deemed a separate violation.

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 OMB 0581-0189 The time required to complete this information collection is estimated to average 30 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.

CDGAC-3 (Rev. 9/2016. Destroy previous editions.)