FV-231-1A PACA License Reinstatement Notice

Form Approved – OMB No. 0581‐0031

PACA LICENSE REINSTATEMENT NOTICE

License Number

Anniversary Date

(barcode)

Your license issued under the Perishable Agricultural Commodities Act expired on the anniversary date listed above as the annual fees were not paid. The license may be reinstated by paying the annual fee plus a $50 reinstatement fee within 30 days of the anniversary date.

Questions? Contact the National License Center at 1‐800‐495‐7222 or email PACALicense@ams.usda.gov.

Bus:

Renewal License Fees

^{Annual License Fee: $XXX.XX}

Branch Fees: $ Reinstatement Fees: $ 50.00

TOTAL FEES DUE $ THIS IS A BILL.

FOR PAYMENT INSTRUCTIONS, REFER TO THE BACK OF THIS INVOICE.

Phone: Fax: Email: Website:

EIN: State of Incorporation or Formation:

Date of Incorporation or Formation:

Type of Business: Nature of Business: Ownership Type:

No. of

Branches:

PRINCIPALS – Owner, Partners, Officers, Directors, Members and/or Managers and stockholders

Name (Last‐First‐ Middle Initial) Home Address ^Title

% of Stock

Please ensure that the information shown above is complete and correct. To make changes or additions, follow the instructions shown on the back of this invoice. Operations without a license can result in an injunction plus civil penalty of $1200 for each offense plus $350 for each day the offense continues. Notice to Customers Making Payment by Check: As part of a Department of Treasury initiative, if you pay your account by check, it will be converted into an electronic funds transfer (EFT). This means the bank will copy your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually occur within 24 hours and will be shown on your regular bank account statement. You will not receive your original check back. The bank will destroy your original check but will keep the copy of it. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient funds, the bank may try to make the transfer up to 2 times at which point your account will be subject to additional administrative charges.

FV‐231‐1A (06‐13)

_{PACA License Reinstatement Notice}

OMB Approved 0581-0031

INSTRUCTIONS: Is all the information shown on the front of this form current and complete? Yes No If “No”, report the changes or additions on the front or in the appropriate space below. If the license is NOT being renewed, explain your reasons under “REMARKS.” This form must be signed, returned with total fees, and received within

_{30 days from the anniversary date shown on the front of this form. Make checks payable to “USDA-PACA.” Please include the license number on the check.}

Return Completed License Reinstatement Notice and appropriate fees by mail to: USDA, PACA Division P.O Box 790327 St Louis, MO 63179-0327 If paying by credit card, submit by fax to (703) 330-4555 Questions, Call (703) 331-4570 or email PACALicense@usda.gov Visit our website at www.ams.usda.gov/paca		Credit Card
		Type of Card: Visa Mastercard Discover American Express Account Number: Exp Date: / Amount: Card Holder’s Name:
FRUITS AND VEGETABLES HANDLED (Item 3 on front) Circle One Fresh Frozen Both	NATURE OF BUSINESS (Item 4 on front) Circle the one that best represents the predominant nature of your operations Wholesaler Commission Merchant Broker Retailer Processor Trucker Food Service Grocery Wholesaler
UNDER “LEGAL STRUCTURE OF BUSINESS” (Item 5 on front) Has changed to: Circle One Sole Proprietor Corporation Limited Liability Company Partnership Limited Partnership Limited Liability Partnership Association Trust Estate			DATE OF CHANGE

_{CHANGES IN OWNERSHIP, PARTNERS, OFFICERS, DIRECTORS, MEMBERS and/or MANAGERS OF LLCs AND STOCKHOLDERS Please update all information requested}

Changes Add Delete

Date of Change

LEGAL NAME Last, First, Middle Initial

Social Security Number

FULL HOME ADDRESS Street, City, State, Zip Code

Title (Including Director)

% of Stock

Main Business Phone Number

Fax Number

E-Mail Address

Federal Employer Identification Number

Changes Add Delete

Date of Change

Trade Name (dba) or Branch

Branch Locations City and State

Signature and Title of Owner, Partner, Member/Manager (LLC) or Officer completing the PACA License Reinstatement Notice. Signature Title Date

REMARKS

Note: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the Perishable Agricultural Commodities Act, 1930, as amended, (7 U.S.C. 499a- 499t) (499c, 499d). Furnishing the requested information is necessary for the administration of the Perishable Agricultural Commodities Act program. 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 0581-0031. The time required to complete this information collection is estimated to average 3 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. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, 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 (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). 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 (TDD). USDA is an equal opportunity provider and employer.

FV-231-1A (06-13) Reverse