F/H Form C(2) (982) Hazelnuts Form for Justification of Sureties

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823

Fax: (503) 678-6825

FORM FOR JUSTIFICATION OF SURETIES

STATE OF _________________________)

) ss.

COUNTY OF _______________________)

__________________________________________________________, a surety whose name is subscribed to the above undertaking, being duly sworn, says that he is one of the sureties named in the forgoing undertaking and is worth the sum specified in said undertaking as the maximum total aggregate liability thereunder, over and above all his just debts and liabilities, exclusive of property exempt from execution, and that he is a resident of ____________________________, County of __________________________, State of _____________________.

_____________________________________________

Subscribed and sworn to before me

this ______ day of _______________, 20____.

_____________________________________

Notary Public for ____________________

My commission expires _________________

STATE OF ________________________)

) ss.

COUNTY OF ______________________)

________________________________________________________, a surety whose name is subscribed to the above undertaking, being duly sworn, says that he is one of the sureties named in the forgoing undertaking and is worth the sum specified in said undertaking as the maximum total aggregate liability thereunder, over and above all his just debts and liabilities, exclusive of property exempt from execution, and that he is a resident of ____________________________, County of __________________________, State of _____________________.

_____________________________________________

Subscribed and sworn to before me

this ______ day of ___________, 20____.

_____________________________________

Notary Public for ____________________

My commission expires _________________

No deferment of restricted obligation will be granted through bonds with sureties acceptable to the Board unless a form for justification of sureties is completed and received by the Board (7 U.S.C 608(d), 7 CFR 982.54 and 7 CFR 982.454).

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 30 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.

F/H Form C(2) (Rev. 01/2017) Destroy previous editions.