OMB No. 0581-0178
FLORIDA TOMATO COMMITTEE NO. ___________________
800 Trafalgar Court, Suite 300 Maitland, FL 32751
Phone (407) 660-1949 Fax (407) 660-1656 CERTIFICATE OF PRIVILEGE NO.________________
www.floridatomatoes.org
REPORT OF SPECIAL PURPOSE SHIPMENT UNDER CERTIFICATE OF PRIVILEGE
SHIPPED TO: ___________________________________________________________________________________________________________________________________
ADDRESS: _______________________________________________________________________ TELEPHONE: ___________________________________________
Name of Carrier: ___________________________________________________________________ Truck License No. ________________________________________
PURPOSE: □ Pickling □ Canning □ Export □ Charity □ Other _________________________________________________________________
No. of Containers Shipped ______________ Container Wt. ___________________ Maturity _________________ Size ____________ Grade __________________ Date Shipped _________________ Loading Point_________________________
The undersigned Shipper certifies to the Florida Tomato Committee (Committee) and the Secretary of Agriculture that these tomatoes are being shipped in accordance with current Marketing Order regulations for use only for the purpose stated. Falsification of information on this government document may result in a fine, imprisonment, or both (18 U.S.C. 1001).
SHIPPER’S NAME ___________________________________________________ Registered Handler No. ____________________ PACA Lic. No. _______________
ADDRESS __________________________________________________________
SIGNATURE ________________________________________________________
Instructions to Shipper: Fill out this report for each Special Purpose Shipment. Sign all four copies. Inspector will mail the original (WHITE) copy to the Committee. Forward the BLUE and YELLOW copies to the receiver. Retain the PINK copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATE. |
No. of Containers Received ____________ Container Wt. _____________________ Date Received _________________ Unloading Point _________________________ If used other than stated by Shipper, specify: __________________________________ ______________________________________________________________________
The undersigned Receiver acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above tomatoes will be used for the purpose indicated. Falsification of information on this government document may result in a fine, imprisonment, or both (18 U.S.C. 1001).
RECEIVER’S NAME _________________________________________________
ADDRESS __________________________________________________________
SIGNATURE _______________________________________________________
Instructions to Receiver: Upon receipt of these forms, promptly complete the BLUE copy and mail to the Committee. Retain the YELLOW copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES PERMITTING SHIPMENTS OF SPECIAL PURPOSE TOMATOES TO YOUR FIRM. |
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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.
FTC-110 (Rev. 01/2017) Destroy previous editions.
| File Type | application/msword |
| File Title | FLORIDA TOMATO COMMITTEE |
| Author | Tim |
| Last Modified By | Pish, Marylin - AMS |
| File Modified | 2017-01-30 |
| File Created | 2017-01-30 |