APC Form 4 Annual Agreement of Inter-Handler Transfers of Pecans

OMB No. 0581-0291

American Pecan Council
P.O. Box 100398
Fort Worth, Texas 76185 (817) 916-0020

[email protected]

ANNUAL AGREEMENT OF INTER-HANDLER TRANSFER OF PECANS

APC Form 4 - Instructions

This report is submitted pursuant to 7 CFR 986.62 and reporting requirements 7 CFR 986.77 and 986.78, and is subject to audit verification by the American Pecan Council pursuant to 7 CFR 986.79. The completed form must be delivered to the American Pecan Council by the tenth day of the month following the first transfer between the two handlers. This form establishes an agreement between the two parties for the fiscal year which ends on September 30th. Form 4 must be renewed each fiscal year.

The following are instructions for completing Form 4 - Annual Agreement of Inter-Handler Transfer of Pecans:

Month of Transfer: Enter the month pecans were first sold to receiving handler.

Handler Number: Leave blank, will be used by APC staff.

1. Enter the Fiscal Year in which this agreement will be effective.

2. Check the box indicating which handler is responsible for paying the assessment and reporting volume on the APC Form 5.

UPON COMPLETION: Read the Certification Statement at the bottom of the form and write/type the Handler/Company name. Then sign and date the form in the spaces provided. Each party in the transfer is to retain a copy of the form then fax or email to AMERICAN PECAN COUNCIL: Fax (866) 232-0085; Email • [email protected].

§986.81 Confidential information: All reports and records submitted by handlers to the Council staff, which include data or information constituting a trade secret or disclosing the trade position, or financial condition or business operations of the handler, shall be kept in the custody of one or more employees of the Council and shall be disclosed to no person except the Secretary of Agriculture.

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 0581-0291. 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.

ANNUAL AGREEMENT OF INTER-HANDLER TRANSFER OF PECANS

This report is submitted pursuant to 7 CFR 986.62 and reporting requirement 986.77 and 986.78, and is subject to audit verification by the American Pecan Council pursuant to 7 CFR 986.79.

FISCAL YEAR: _________________________________________

HANDLER NUMBER: ___________________________________ (for Committee use)

This is an annual report of pecans transferred between handlers designating which handler is responsible for submitting assessments to the APC for all transactions taking place between the two handlers and shall be submitted in compliance with the requirements of 7 CFR 986.62. Completion of this form does not exempt either handler from reporting inventory on APC Form 5. In executing this form, both handlers respectively certify to the Council and to the U.S. Department of Agriculture the correctness and completeness of their statements.

Who is responsible for paying the assessment and reporting on APC Form 5 (check appropriate box):

Transferring Handler [ ] Receiving Handler [ ]

To be completed by Transferring Handler To be completed by Receiving Handler

________________________________________ ________________________________________

Name of Handler/Company Name of Handler/Company

________________________________________ _________________________________________

Signature Signature

________________________________________ _________________________________________

Date Date

Certification Statement: 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, of the United States Code, which provides for a penalty of a fine for individuals and for organizations or imprisonment, or both.

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.

APC Form 4 (Rev. 9/2019)