CWB 4 and 5 Inventory Report

California Walnut Board OMB No. 0581-0178

101 Parkshore Drive, Suite 250 CWB Form #4 & #5

Folsom, CA 95630 Due Date:

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: 1. Report certified inshell and shelled inventory as indicated.

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.

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

4. Mail a signed original to the California Walnut Board (CWB) office on or before .

WALNUT INVENTORY (in pounds)
	Inshell	Shelled
Certified Walnuts: (All Areas)
Uncertified Walnuts
TOTAL

Handler: _______________________________________________________________________________

By: ___________________________________________________________________________________

Title: _____________________________________________ Date: ______________________________

T

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.

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To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

he 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.

Rev. 04/09