PMC 8.443 (993) CA Dried Prunes Claim for Reserve Pool Proceeds

OMB No. 0581-0178

CLAIM FOR RESERVE POOL PROCEEDS

To: Prune Marketing Committee Date _________________________, 20___

3840 Rosin Court, Suite 170

Sacramento, CA 95834

1. CLAIM: Claim is hereby made by the undersigned for reserve pool proceeds on prunes delivered under the name and address of _______________________________________________________________, as follows:

Crop Year	Handler	Amount	Check No.	Date	Quantity

II. BASIS OF CLAIM: The basis of this claim is marked with an X; below:

• The prunes were owned by me/us.

• The proceeds were assigned to me/us.

• My leasehold share is _________ %. The remainder belongs to:

Percent	Name	Address

• I was appointed administrator or executor of estate of payee, now deceased, on ______, 20__, by ____________________________________________ (Name and Address of Court) in Probate Case No. _______________________________.

• I am (we are) the sole surviving heir(s) of payee, deceased; no other persons are entitled to share in these proceeds,

• Other -as follows: ________________________________________________________________

III. INDEMNIFICATION: In consideration of remittance to the undersigned of the pool proceeds shown above, I (we) hereby agree to hold and keep the Prune Marketing Committee (Committee) harmless from and indemnified against any liability or loss arising there from or any claim or demand by any other person claiming such proceeds.

________________________________________________________________________________________________________

(Claimant’s Signature) (Mailing Address)

________________________________________________________________________________________________________

(Claimant’s Signature) (Mailing Address)

IMPORTANT NOTICE: The issuance of a false certificate knowing it to be false is a violation of title 18 section 1001 of the United States Code, which provides a penalty or imprisonment, or both.

INSTRUCTIONS: This form must be completed, signed by all claimants, and submitted to the Committee together with all documents necessary to substantiate it, such as assignments, leases, certified copies of letters of administration, court orders, affidavits of right to receive monies due a deceased person, orders for the disposition of estates without administration, or other legal documents evidencing authority to receive the claimed proceeds. These documents will be promptly examined and returned.

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.

PMC 8.443 (Exp. x/xxxx) Destroy previous editions.