CWB 4 & 5 (984) CA. Walnuts - Inventory Report

OMB No. 0581-0178

California Walnut Board

101 Parkshore Drive, Suite 250 Due Date: __________, 20__

Folsom, CA 95630

Ph (916) 932-7070 Fax (916) 932-7071

INVENTORY REPORT

This inventory report is submitted in compliance with the requirements of the Federal Marketing Order No. 984, as amended. In executing this form, the handler respectively certifies to the California Walnut Board and to the U.S. Department of Agriculture as to the correctness and completeness of their statement.

Instructions

Section 1 (this page):

1. Report certified inshell and shelled inventory as indicated (product that you, as the handler, own)

2. Report uncertified inventory that will be inspected and sold as inshell by inshell weight and report inshell and shelled inventory that will be inspected and sold as shelled by kernel weight (product that you, as the handler, own)

3. If you are not holding any inventory, write “NONE” on the form.

Section 2 (next page):

1. If you are holding inventory for another party, including but not limited to, a grower, another handler, or an exporter for custom packing or storage (product NOT owned by you), please complete Section 2 on the next page.

2. Please report certified and uncertified shelled and inshell inventory held in pounds and list the name, address and phone number of the party that owns the product.

3. Please use an additional sheet if you need more space.

Mail a signed original to the California Walnut Board (CWB) office on or before ________________, 20___.

WALNUT INVENTORY – HANDLER-OWNED PRODUCT
	Inshell Pounds	Shelled Pounds
Certified Walnuts:
Uncertified Walnuts:
TOTAL

Handler: _______________________________ Signature: _______________________________________

Print Name:_____________________________ Title: _______________________ Date: ___________________

The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of Title 18, Section 1001, United States Code, which provides for the penalty of a fine of $250,000 for individuals and $500,000 for organizations or imprisonment of not more than five years, or both.

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 10 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.

Handler Name:__________________________________________________________

WALNUT INVENTORY – HELD FOR THIRD PARTIES (list each separately)
	Inshell Pounds	Shelled Pounds	Product owned by:
Certified Walnuts:			Name:
Uncertified Walnuts:			Address:
Total:			City/State/ZIP:
			Phone:
			Email:
	Inshell Pounds	Shelled Pounds	Product owned by:
Certified Walnuts:			Name:
Uncertified Walnuts:			Address:
Total:			City/State/ZIP:
			Phone:
			Email:
	Inshell Pounds	Shelled Pounds	Product owned by:
Certified Walnuts:			Name:
Uncertified Walnuts:			Address:
Total:			City/State/ZIP:
			Phone:
			Email:

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.

Form CWB #4 & #5 (Exp. x/xxxx) Destroy previous editions.