No Form number (959) So. TX Onions Relief or Charity Certification for

OMB No. 0581-0178

SOUTH TEXAS ONION COMMITTEE

901 Business Park Drive, Suite 500, Mission, TX 78572

Phone: (956) 584-9331 Fax: (956) 581-3912

RELIEF OR CHARITY CERTIFICATION

FOR HANDLING ONIONS WHICH FAIL TO MEET

THE SOUTH TEXAS ONION RULES AND REGULATIONS

Effective Date: ________________ Expiration Date: ________________

No shipments of special purpose onions may be made unless this form is completed and returned to the South Texas Onion Committee (Committee) (7 CFR 959.126). Two (2) copies of this Certification are enclosed. If you receive onions which do not meet the South Texas Onion Rules and Regulations, from South Texas Onion Handlers, to be used for charitable and relief purposes, you must complete this certification and return one copy to the Committee office, retaining the other copy for your files.

It is understood and agreed to by me, the undersigned applicant, that all onions granted a Certificate of Privilege for Special Purpose Shipments, by virtue of this application and corresponding Special Purpose Shipment Reports, must be used for the purpose stated in this application and any deviation or infringement of this privilege which shall become known to me will be reported to the Committee promptly. Further, I will not knowingly sell or cause to be sold onions which have been granted a Certificate of Privilege and are to be used in violation of Certificate. I acknowledge that making of a false or fraudulent statement for the purpose of influencing the actions of a government agency shall, upon conviction, be subject to a fine or imprisonment, or both (18 U.S.C. 1001).

Print Name Signature

Firm Name Title

Telephone Number Fax Number Date

Email Address

Street or Box Number, City, State, and Zip Code

Physical address if different than above mailing address

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 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.