RAC-5 (989) Notification of Intention to Handle Raisins & Appl

OMB No. 0581-0178

RAISIN ADMINISTRATIVE COMMITTEE

2445 Capitol Street, Suite 200

Fresno, California 93721

Phone: (559) 225-0520

NOTIFICATION OF INTENTION TO HANDLE RAISINS

AND APPLICATION FOR INSPECTION POINT

The __________________________________________________ hereby gives notice that it intends to handle raisins as a packer (§ 989.14), or handler (§ 989.15), as defined in Marketing Order No. 989 regulating raisins produced from grapes grown in California, and requests that the premises outlined in the description on file with the Raisin Administrative Committee (RAC) be designated as an inspection point for the 20___ crop year.

The undersigned declares the following concerning the ownership, organization and management of the company named:

Name of Company:

Principal Address:

Mailing Address:

Phone Number: ___________________________________ Fax Number:

Email Address:

Type of Company: □ Corporation □ Partnership □ Cooperative □ Sole Proprietor

Tax Identification Number (TIN) ________________________________

Officers, owner, or managers:

Name		Title
Name		Title
Name		Title

Location of plant(s) and receiving point(s) to be designated as inspection point(s):

□ Premises description on file with RAC still applicable. □ Premises description attached.

Signature		RAC Approval
Title		Title
Date		Date

Application requires signatures of both above-named parties to be official.

The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended.  The authority for requesting the information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674).  Furnishing the requested information is necessary for the administration of the marketing order program.  Submission of the Tax Identification Number (TIN) is mandatory, and will be used to determine affiliation or entity identity.  If a TIN is not disclosed, the information provided will not become invalid if another means of identifying the entity exists.

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.

RAC-5 (Exp. x/xxxx) Destroy previous versions.