FV-198 Raisin Form No. 2

--- - -

--

---- - -.---

REPRODUCE LOCALLY. Include form number

-

end date on eU rtlproductlons.
U.8. Dl!PARI'IIEIIIT
01'AGRiCUL
TUg
AGRICULTURAL

MARKET1NG

FORMAPPROVED OMS NO. 0681-0178

SEIMCE

FflUrr ANDVEGETABLE
~

Raisins

- Section

RAISIN FORM NO.2
8e Certification

of Processor

SM:tIon Be"41 fA} IIf 11I8
Agdt:uJtInIMMIt«lnt1A~
Act IIf t837. /1IfWId8Nt ."., ,.,..
",110.""...
trw Nt:h -"
vItII#IoIL &dI drI tlMt sut:h vIOI6iJont:GIItImIa IMII be d-.l.
.,.,.,.
vItRtIon. hI8

IlItowlntllt
tobe,...

The following

,.. vk18t1rm
IIf,. U.s.c. tOOtwIrk:h
pnI"'" trw. tine", ~

statements

are made in accordance

or Reseller

thepnwb/tIn8of SctIon "., ",., be fined/lOt..
tJltIM ID ." ~

",both.

with the Privacy Act of 1974 (5 use 552a).

IIf the UnImI sr.ta

.

thM '6O",1iiIn th8n '6.000

lit ."., IfI8tt8r within fa /W*dk:tIon.

.

According to the Paperwork Reduction Act of 1995. an agency may not conduct or sponsor. and a person Is not required to respond to . 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 15 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.
The U.s. ~partment
of Agriculture
(USDA) prohibits discrimination in aU its programs and activities on the baSis ofrace. color. national origin. age. disabiUty. and where applicable,. sex.
marital status. familial status. parental status. religion. sexual orientation. genetic information. political beliefs. reprisal. or because all or part of an
Individual's income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require
alternative means for communication
of program information (BraiDe. large print. audiotape. ete.) should contact USDA's TARGET C81ter at (202) 720-2600
(voice and TOO). To file a complaint of discrimination.
write to USDA. Director. Office of Civil Rights. 1400 Independence
Avenue. S.W.. Washington. D.C.
20250-9410.
or call (800) 795-3272 (voice) or (202) 720-6382 (TOD). USDA is an equal opportunity provider and employer.

I RR1U3Y CERTIFY to the U.S. Department of Agriculture that I have acquired the raisins or raisin residual material from foreigIL-producedraisins
covered by this c:eItific:atioo;that I will use or sell them for use only in production of alcohol, syrup for iDdustriaI use, raisin paste, or animal feed, as
permitted by the Regulation GovemiDg the Importation of Raisins (1 CPR 999.300) and I am a: (Cluck oil. or 11IO,.U ~.)

D

PRODUCER OF ALCOHOL

1. DAn-OF

3.

D

PRODUCER

OF SYRUP FOR

INDUSTRIAL

USE

PURCHASE

D

PRODUCER
OF RAISINPASTE
I

D:UCER

OFANINAL

D

RESELLER

2. Plf'CE OF PURCHASe fC/ly Md StmI
4. USDA CERTIRCA

NAMI! AND ADDRESS OF IMPORTER OR SELLER

1E OF QUAU"TY

AW:J CONDmON

NUMBER

5. RAISINS OR RAISIN RESIDUAL MATERIAL ACQUIRED:
:

DATE

NUMBER OF CONTAINERS

TOTAL NET WEIGHT
(Pound&I

NAMEANDADDRESSOF RRM

NUMBER OF CONTAINERS

SIGNATURE OF AUTHORIZED OFFICIAL

TITlE

FV-198105-011(Dutroy prevJou BdltIonJ

TOTAL NET WEIGHT
(PounrbJ