No Form Number (906) Texas Citrus Certificate of Privilege

OMB No. 0581-0189

TEXAS VALLEY CITRUS COMMITTEE Telephone: (956) 581-2190

901 Business Park Drive, Suite 400 Fax: (956) 584-3307

Mission, Texas 78572

CERTIFICATE OF PRIVILEGE NO. __________

I, the undersigned, hereby certify to the Secretary of Agriculture and to the Texas Valley Citrus Committee that I have read, fully understand, and will comply with, the foregoing rules that govern the handling of citrus for processing or for manufacturing for conversion into specified by-products, relief or charity. I further understand that noncompliance is a violation of the Agricultural Marketing Agreement Act, and is subject to a fine of up to $1,100 for each violation.

By: ______________________________ ___________________________ ____________

Name (please print) Signature Date

Firm Name: ___________________________________ Title:____________________________

Address:

Mailing Address, City, State, and Zip Code

Physical Address (if different than mailing address): __________________________________________

Phone: _______________________________ Fax: __________________________________

Person in charge of Special Purpose forms:

Purpose of Shipments:  Processing  Relief/Charity  Otherwise Diverted ______________

(check applicable boxes)

Where will shipments originate?

List Names and Addresses of Consignees below:

APPROVED BY: ______________________________________ DATE:____________________

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 5 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.

(Exp. x/xxxx) Destroy previous editions.