SC-212 915-Avocados Report of Special Purpose Shipment

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SPECIALTY CROPS PROGRAM		REPORT OF SPECIAL PURPOSE SHIPMENT UNDER CERTIFICATE OF PRIVILEGE				Avocado Administrative Committee P.O. Box 900188 Homestead, FL 33090-0188 Tel: (305) 247-0848
SHIPPED TO
ADDRESS (City, County, State, and Zip Code)
NAME OF CARRIER					TRUCK LICENSE NUMBER
PURPOSE: □ Seed □ Charity (fresh) □ Processing
NUMBERS OF CONTAINERS SHIPPED			CONTAINER WEIGHT	NUMBER OF CONTAINERS RECEIVED				CONTAINER WEIGHT
DATE SHIPPED	LOADING POINT			DATE RECEIVED			UNLOADING POINT
CERTIFICATION STATEMENT: The undersigned certifies to the Committee and the Secretary of Agriculture that these avocados are being shipped in accordance with current Marketing Order Regulations for use only for the purpose stated. I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment.				If used other than stated by Shipper, specify:
				CERTIFICATION STATEMENT: The undersigned acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above avocados will be used for the purpose indicated. I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment.
NAME OF SHIPPER
REGISTERED HANDLER NUMBER (if applicable)
PACA LICENSE NUMBER (if applicable)				NAME OF RECEIVER
ADDRESS (City, County, State, and Zip Code)				ADDRESS (City, County, State, and Zip Code)
SIGNATURE OF SHIPPER				SIGNATURE OF RECIEVER
SHIPPER INSTRUCTIONS: Fill out this report for each Special Purpose Shipment. Sign all four (4) copies. Mail the original (white) copy to the Committee. Forward the yellow and pink copies to the receiver. Retain the gold copy for your files. FAILURE TO COMPLY CONSTITUTES A VIOLATION OF MARKETING ORDER NO. 915.				RECEIVER INSTRUCTIONS: Upon receipt of these forms, promptly complete the pink 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 AVOCADOS 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 OMB 0581-0189. The time required to complete this information collection is estimated to average 6 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.

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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.

SC-212 (Rev. 06/2017. Destroy previous editions.)