RAC-106 (989) Application to Purchase Reserve Pool Raisins

OMB No. 0581-0178

RAISIN ADMINISTRATIVE COMMITTEE

2445 Capitol Street, Suite 200

Fresno, California 93721

Phone: (559) 225-0520

APPLICATION TO PURCHASE RESERVE POOL RAISINS TO FULFILL AN OFFER TO SELL

PURSUANT TO ANNOUNCEMENT ___

Contract No. ________________

The undersigned Packer hereby requests approval by the Raisin Administrative Committee (RAC) of this application. It is understood that upon approval of this application, the Packer has agreed to purchase, and the RAC has agreed to sell, the quantity of natural condition raisins specified herein for use in fulfilling the Packer’s accepted “Offer to Sell” pursuant to the U.S. Department of Agriculture’s Announcement No. ________ Invitation No. __________.

Varietal Type	Net Pounds per Shipping Case	No. of Shipping Cases	Total Net Pounds Packed Weight	Factor per Annc./ Inv. No. ____	Equiv. Natural Condition Weight = Packed Weight Divided by Factor:	Amount to be Invoiced at $_____ per ton ($._____ per lb.)
					Total

As a condition of RAC approval of this application and in conformance with section 989.73(d) of Marketing Order No. 989, the undersigned Packer agrees to furnish to the RAC one copy of the commercial bill of lading and one copy of the USDA Inspection Service’s Certificate of loading relative to each shipment of raisins from the tonnage released pursuant to this application.

Packer			FOR RAC USE ONLY
Address			Date Received
Title			Application No.
E-mail			Tonnage Approved
			Date Approved
Signature			By:

The making of any false statement 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 or imprisonment of not more than five years, or both.

This report is required by law (7 U.S.C. 608d, 7 CFR 989.167). Failure to report can result in a fine of $2,750 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 0581-0178. 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.

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.

RAC-106 (Exp. x/xxxx) Destroy previous versions.