Form Fv-251 - Imported Pistachios - Rework & Failed Lot Disposition Report (Page 2 of 2) in pdf

REPRODUCE LOCALLY – Include form number and date on all republications

OMB No. 0581-0215

Form FV-251 – Imported Pistachios – Rework & Failed Lot Disposition Report (continued)

Section D - Non-Human Consumption: Complete this section if the failed lot was shipped to a non-human

consumption outlet.

Pounds shipped:________________ BOL #:_______________________

Product Shipped To:____________________________ Phone #: _______________________

Address:_______________________ City: _____________ State: _____ Zip code:_________

Description of use:_____________________________________________________________

Section E - Export: Complete this section if the failed lot was exported.

Pounds shipped:________________ BOL #:_______________________

Customer:___________________________ Country:________________________________

Address:_____________________________________________________________________

Section F – Destroyed: Complete this section if the failed lot, or a portion of the failed lot, was destroyed.

Pounds destroyed:___________________

Method of destruction:___________________________________________________________

Location of destruction:__________________________________________________________

Verified by:_____________________________________ Of (Agency):__________________

Importer Signature: _______________________________ Date:_________________________

Name:__________________________________________ 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 a penalty of a fine for

individuals and for organizations or imprisonment, 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 0581-0278. The time required to complete this information collection is estimated to average 12

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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,

national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual

orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any

public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative

means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center

at (202) 720-2600 (voice and TDD). 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.

FV-251 (Rev. 05/2014. Destroy previous editions)

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Form Fv-251 - Imported Pistachios - Rework & Failed Lot Disposition Report Page 2