CAC-402 (905) FL. Citrus--Shipments under Grower Tree Run Certif

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE Shipment No. _____________________

P.O. Box 24508

Lakeland, FL 33802-4508

Phone: (863) 682-3103

Fax: (863) 683-9563

Email: Info@citrusadministrativecommittee.org

REPORT OF SHIPMENTS UNDER GROWER TREE RUN CERTIFICATE

Variety of Citrus	Legal Description of Grove	1-3/5 Bu. Boxes Equivalent
	Total 1-3/5 Bushel Boxes

Truck/Trailer License No. ___________________________________ Shipping Date ______________

The undersigned certifies to the Citrus Administrative Committee (Committee) and the Secretary of Agriculture that this citrus shipment is being shipped in accordance with current Marketing Order No. 905 regulations. I (we) realize that the making of a false statement, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statutes, which provide for fine and imprisonment.

Grower___________________________________________ Grower Tree Run Certificate No. _______

Address

Signature of Grower

Instructions to Grower: Complete this report for each shipment. Sign all copies, and return the white copy to the Committee. The yellow copy stays with the shipment, and the pink copy is retained by the Road Guard Station. Retain the gold copy for your files.

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 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.

CAC Form 402 (Exp. X/XXXX) Destroy previous editions.