CDGAC-8 (925) Food Donation Form

OMB No. 0581-0189

Food Donation Form California Desert Grape Administrative Committee

82-901 Bliss Avenue, Indio, CA 92202-1736
Office: (760) 342-4385; Facsimile: (760) 342-0485

Producers and Handlers Section:

1. Producer/Handler: Loading Date:

2. Location of Load, Inspection Point:

(Where this load is being picked-up)

3. List boxes (lugs) of grapes to donate from inspections:

No.	Variety(s) and Inspection Certificate No.	Inspection Date	Lug Weight	Number of Lugs	Label
1
2
3
4
5

4. Signed By: Date:

(Signature of person representing Producer/Handler in charge of this loading at handling facility)

Charity Information Section:

5. Name of Charity:

6. How many boxes of grapes (lugs) were picked up for this load:

7. Charity Recipient (Driver) Signature: Date:

The making of false statement or representation on this form, knowing it to be false, is a violation of Title 18 section 1000, United States Code (USC), which provides for the penalty of a fine or imprisonment, or both. This report is required by law (7 USC 601-674, CFR 925). Failure to report can result in a fine for each 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 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.

Instructions:

Charity Driver:

1. Request the person in charge of this loading completes the “Producers and Handlers” section.

2. Charity Driver completes the “Charity Information” section

3. Give the ORIGINAL and THIRD copies to the person in charge of the loading at the handler’s facility.

4. Retain SECOND copy for Charity’s record.

Producers and Handlers:

The ORIGINAL is the handler’s record of grapes picked up by the charity organization. Please forward the THIRD copy to the California Desert Grape Administrative Committee by facsimile, email or U.S. Mail within two days of fruit picked up by charity.

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-8 (Exp. X/XXXX) Destroy previous versions.