No Form number Annual Allotment Certificate, Class I

ANNUAL ALLOTMENTCERTIFICATE
CLASS1

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DATE_I_I_

#0581-0178

By
Name of HANDLERor,
If DEFICIENCY,Other GROWER

Signature of Handler
or CommitteeAgent

The makingof a false certification,knowingIt to be false, 10an agenq of the U.S. is a violetionof Tille 18, Section1001. of the U.S. Codewhich
providesfer 8 penallyof not 11IOI8
Ihan$10,000at 1,.lsonmenlof not moreIhanlive rears,or both.

.

WHITE CommiIlBe0IIice YEIJ.OW

- Attach

10 f'IIldIase

Vouchet

Pili(.

Balance

HIIKIer

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_ 1_,_

DATE

OMB

Name of HANDLERor,
If DEFICIENCY,
Other GROWER

#0581-0178

By
Signature of Handler
or CommitteeAgent

The msfcingcI a false eBI1iIcalion,k/IoIIing It 10 be false, to an agency 01 the U.S. is , violation r:I Tille 18, Seeton 1001. of !he U.S. Code YofIich
1811I5,at both.

providesfer, penaly01notmorethan$10.000or ImJrlsonmenl
of not morethanlive
WHITE- ComaIitIaa
0Ib

YELLOW

- AItach 10 Pun:haseVoucher

-

PINK Handler

Balance

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DATE

OMe #0581-0178

_ '_'_

Name of HANDLERor,
iI DEFICIENCY,Other GROWER

By
Signature of Handler
or CommitteeAgent

The maki1g01a taIse cartBlcaUon, knowing110 be false, 10an agencyof lie U.S. Is a ~
01Tit'- 18. Section1001,of tie U.S. Codewhich
providea br a peMty of not 11IOI8 lIan $10,000 or imprisonment of not more lllan he }/taS, or both.
WHITE - CDmmiIIBe0IIice YELLOW. AIach to Purchase Voucher 'ilK.

Handler

Balance

--------------------------------------------OMB #0581-0178

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Name of HANDLER
or,
if DEFICIENCY,Other GROWER

By

SIgnature of Handler
or CommitteeAgent

T

C
H

h 10be tab.. to an .ncr

The maldngof 8 false

certiIcetJon,

provides

of not RIOI8 Ulan $10.000

~

8 pBllaItr

knowing

or Imprisonment

WIfiE

of the US. Is a violationof Tille 18, Sec1Im 1001, of the U.s. Code .hich

of not more

-ComniIlBe

than

0IIIce

Ave years, 01 both.
YELLOW

-Attach

III Purchase

Voucher

PINK. Handler

Balance

--------------------------------------------OMB #0581-0178

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DATE

Name of HANDLERor,
If DEFICIENCY,Other GROWER

By
Signature of Handler
or Committee
Agent

T

C
H

Tha making of 8 false certilicalion, ~ng
~ 10 be false, 10 an /I9"I1CYof In8 U.s. is e viOlaliOftof ToUe18, Sec1Ion 1001, of !he U.S. Code which
providas br 8 penaltr of n01 more Ihan $10.000 or Imprisonment of not more Ulan Ive )'1181$.or both.

Balance

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-

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CLASS ONE BASE CERTIFICATE
FAR WEST SPEARMINT OIL ADMINISTRATIVE

COMMITTEE

The CLASS ONE (SCOTCH) BASE as of

Is Established At

Ibs.

for

Effective

Arx;ordlngto the P~

Reduction Act of 1995, an agenoy may not conduct or spOnsor, and a person Is 1ICJt
requl1ed to
respond to a coI1ectionof information unlftss it displays a valid OMS controf number. The valid OMS control number for this
infomJaOOncollection Is 0581-0178. The ~
required to complete this information ooIIec6on is estimated to all8l8g8 ten
minutes per response, Including the time for reviewing instructions. se81Ching existing data sources, gathering and malnt8lnlng
the data needed, and completing and revf8wfrJg the coIIectJon of InformaIJon.

The U.S. Deparlment of Agriculture (USDA) prohibits disaimination In sit Its programs and BCtlVlties on the basis of race, color.
national origin, age, disabiTIty, and where applicable, sex, marital status, famlHal status, paranta/6tatus,
religion, selCuaI
orientetion, genetic information, political beliefs, reprisal, or because aUor patf of an Ind"lViduaJ'sincome ;s derived 110many
public assistance program (Not aJ/ prohibited bases apply to all programs.) PetSOII$ with disabiRties who require alternative
means for communication
of program Information (BraIlle, large print, audiotape, etc.) should contact USDA ~ TARGET ContSf' at
(202) 72CJ..2600 (voice and TOO). To file a r;ompJalnt of dIsct1mlnation, write to USDA, Director, Office of Civil Rights, 1400
D.C. 20250-9410,
or calf (800) 7~3272
(voice) or (202) 720.&82 (TOO). USDA is an
Independence Avenue, S.W, Washington,
equal opportunity

provider and employer.