Form CWB-2 Report of Walnut Assessment

OMB NO. 0581-0344
CWB Form #2

California Walnut Board
110 Woodmere Rd., Suite 250
Folsom, CA 95630-4726
Ph (916) 932-7070 Fax (916) 932-7071

REPORT OF WALNUTS EXEMPT FROM ASSESSMENTS
This report of walnuts delivered to noncompetitive outlets that are exempt from assessments 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:

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Report deliveries that are exempt from assessments (Walnut Marketing Order 984.67).
Complete the information below.
Report weight as INSHELL (using your calculated conversion rate for the season).
Submit a copy of the form to the California Walnut Board (CWB) within 10 days of activity.

For each delivery, complete the shipped to name, INSHELL weight(s), lot or solicitation number, and date
shipped in the table below:
Delivery of walnuts to Noncompetitive Outlets: i.e. charitable institutions, relief agencies, governmental
agencies (Section 32 purchases), and diversion to animal feed or oil manufacture pursuant to an authorized
governmental diversion program.
SHIPPED TO
(INSTITUTION/OUTLET NAME)

Completed By:

INSHELL POUNDS

LOT ID /
SOLICITATION #

DATE
SHIPPED

Handler Name:
By:

Title:

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 0581-0344. 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.

CWB Form #2 (Exp. 5/31/2027)