CWB 4 & 5 (984) CA. Walnuts - Inventory Report

OMB No. 0581-0178
CWB Form #4 & 5

California Walnut Board
110 Woodmere Rd., Suite 250
Folsom, CA 95630
Ph (916) 932-7070 Fax (916) 932-7071

Due Date: __________, 20__

INVENTORY REPORT
This inventory report is submitted in compliance with the requirements of the Federal Marketing Order No. 984, as amended. In executing
this form, the handler respectively certifies to the California Walnut Board and to the U.S. Department of Agriculture as to the correctness
and completeness of their statement.

Instructions
Section 1 (this page):
1.
2.

3.

Report inshell and shelled inventory as indicated (product that you, as the handler, own)
Report inventory on an on-hand basis. Inshell pounds on hand should be reported as inshell pounds. Shelled pounds
on hand should be reported as shelled pounds.
If you are not holding any inventory, write “NONE” on the form.

Section 2 (next page):
4.

5.
6.

If you are holding inventory for another party, including but not limited to, a grower, another handler, or an exporter
for custom packing or storage (product NOT owned by you), please complete Section 2 on the next page.
Please report shelled and inshell inventory held in pounds and list the name, address and phone number of the party
that owns the product.
Please use an additional sheet if you need more space.

Submit a signed original to the California Walnut Board (CWB) office on or before ________________, 20___.

1. WALNUT INVENTORY – HANDLER-OWNED PRODUCT
INSHELL POUNDS
CONVENTIONAL

ORGANIC

SHELLED POUNDS
CONVENTIONAL

ORGANIC

TOTAL
Handler: _______________________________

Signature: _______________________________________

Print Name: _____________________________ Title: _______________________ Date: ___________________
The making of any false statements 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, United States Code, which provides for the penalty of a fine for
individuals and for organizations or imprisonment, or both.

Form CWB #4 & #5 (Exp. 4/30/2027) Destroy previous editions.

OMB No. 0581-0178

Handler Name: __________________________________________________________

2. WALNUT INVENTORY – HELD FOR THIRD PARTIES (list each separately)
Inshell Pounds
CONVENTIONAL

ORGANIC

Shelled Pounds
CONVENTIONAL

ORGANIC

Total:

Product owned by:
Name:
City/State/ZIP:
Phone:
Email:

Inshell Pounds
CONVENTIONAL

ORGANIC

Shelled Pounds
CONVENTIONAL

ORGANIC

Total:

Product owned by:
Name:
City/State/ZIP:
Phone:
Email:

Inshell Pounds
CONVENTIONAL

ORGANIC

Shelled Pounds
CONVENTIONAL

ORGANIC

Product owned by:
Name:
City/State/ZIP:

Total:

Phone:
Email:

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.

Form CWB #4 & #5 (Exp. 4/30/2027) Destroy previous editions.