Form SC-24 Positive Lot Identification Stamp/Die Request Form

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OMB No. 0581-0125

SPECIALTY CROPS INSPECTION DIVISION
POSITIVE LOT IDENTIFICATION
STAMP(S)/DIE(S) REQUEST FORM
A. Stamp Description
Stamp Location (Applicant):

Stamp Manufacturer:

Stamp Manufacturer: Please reproduce, at the Applicant’s expense, _______ hand stamps or________ in-line coder printing dies bearing the approved USDA
Federal-State Inspection logo with the following permanently affixed accountability number(s).
District
Number

Inspection
Number

Office/Market
Number

____ Inches

House
Number

____ Inches

B. Applicant’s Request
As a duly authorized agent of the above firm (Applicant), I hereby request that the above stamp/die order be approved and produced. I/We agree to be
responsible for all charges assessed by the stamp manufacturer for this order. I also acknowledge that all stamps/dies ordered are the exclusive property of the
United States Department of Agriculture and/or the___________________________________________________Federal-State Inspection Service.
______________________________________________________
Applicant’s Authorization Signature
E-Mail Address:

___________________________________
Date of Request

C. State/District Authorization
I have reviewed the above request and give approval for the order to be processed.
_______________________________________________________
State/District Authorization Signature

___________________________________
Date of Request

D. Federal Authorization
All stamps/dies which make reference to or imply that a product has been USDA or Federal-State inspected are accountable items and are the property of the
United States Department of Agriculture. No stamps/dies shall be produced without specific written consent of the Federal Program Manager/ Supervisor.
________________________________________________________
Federal Program Manager/Supervisor’s Signature
NOTE:

These stamps/dies are to be
mailed to the Federal-State District
Supervisor who will distribute
them.

___________________________________
Date of Authorization

MAIL STAMPS/DIES TO

E. Manufacturer’s Statement
I certify that each stamp/die produced by this firm bears a permanent accountability number and the only stamps/dies produced by this firm with markings
referencing the USDA and/or the ______________________Federal-State Inspection Service are those that have been authorized in writing by the USDA.
_____________________________________________
Manufacturer’s Signature of Compliance

__________________________________________
Title

_________________________________
Date of Shipment

F. Local/District Receipt
I have received_______________ (quantity) stamp/dies bearing the following permanently affixed accountability number(s).
____________

____________

____________

____________

____________

____________

____________

____________

____________

____________

____________

____________

_______________________________________________________
District Supervisor’s Signature

___________________________________
Date Received

G. Authorized PIQ-PLIDS Firm Representative/Inspector’s Receipt
I have received the above listed stamps/dies and they are now my responsibility.
_______________________________________________________
Authorized Signature
SC-24 (6-2017)

___________________________________
Date Received

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 is 0581-0125. The time required to complete this information collection is estimated to average 1 hour
per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of
information.
Non-Discrimination Policy: 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.

SC-24 (6-2017)