CAC 110 905-FL. Citrus Report of Shipments under Certificate of

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE

P.O. Box 24508

Lakeland, FL 33802-4508

Phone: (863) 682-3103

Fax: (863) 683-9563

Email: info@citrusadministrativecommittee.org

REPORT OF SHIPMENTS UNDER REPACKING CERTIFICATE OF PRIVILEGE

As required by Marketing Order No. 905, regulating the handling of

oranges, grapefruit, tangerines, and tangelos grown in Florida

Shipped to _____________________________________ Address _______________________________

Truck License No. _________________ Shipping Date ___________ Certificate No. ________________

Variety of Citrus Fruit	Number of Containers	Fruit Size	Type of Container	Size of Container	Manifest Number
Total Containers

The undersigned certifies to the Committee and the Secretary of Agriculture that this citrus shipment is being shipped in accordance with current Marketing Order No. 905 Regulations for Repacking. 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.

Repacking Shipper

Address

20___-20___ Season

Repacking Certificate of Privilege No. ________

Signature of Repacking Shipper ______________________________________

Instructions to Repacking Shipper: Complete this report for each repacked shipment. Sign all copies and mail the white copy to the Committee. The pink copy goes with the shipment. Retain the canary copy for your files. Give the goldenrod copy to the trucker.

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 0581-0189. The time required to complete this information collection is estimated to average 7 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 110 (Exp. X/XXXX) Destroy previous editions.