OMB No. 0581-0178

FTC-110 (Exp. 3/31/2024) Destroy previous editions.

FLORIDA TOMATO COMMITTEE NO. ___________________

800 Trafalgar Court, Suite 300 • Maitland, FL 32751 

Phone (407) 660-1949 • Fax (407) 660-1656 CERTIFICATE OF PRIVILEGE NO.________________

www.floridatomatoes.org

REPORT OF SPECIAL PURPOSE SHIPMENT UNDER CERTIFICATE OF PRIVILEGE

SHIPPED TO: ___________________________________________________________________________________________________________________________________

ADDRESS: _______________________________________________________________________ TELEPHONE: ___________________________________________

Name of Carrier: ___________________________________________________________________ Truck License No. ________________________________________

PURPOSE: □ Pickling □ Canning □ Export □ Charity □ Other _________________________________________________________________

No. of Containers Shipped ______________ Container Wt. ___________________

Maturity _________________ Size ____________ Grade __________________

Date Shipped _________________ Loading Point_________________________

The undersigned Shipper certifies to the Florida Tomato Committee (Committee) and 

the Secretary of Agriculture that these tomatoes are being shipped in accordance with 

current Marketing Order regulations for use only for the purpose stated. Falsification of 

information on this government document may result in a fine, imprisonment, or both 

(18 U.S.C. 1001).

SHIPPER’S NAME ___________________________________________________

Registered Handler No. ____________________ PACA Lic. No. _______________

ADDRESS __________________________________________________________

SIGNATURE ________________________________________________________

Instructions to Shipper: Fill out this report for each Special Purpose Shipment. Sign all 

four copies. Inspector will mail the original (WHITE) copy to the Committee. Forward 

the BLUE and YELLOW copies to the receiver. Retain the PINK copy for your files. 

FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATE.

No. of Containers Received ____________ Container Wt. _____________________

Date Received _________________ Unloading Point _________________________

If used other than stated by Shipper, specify: __________________________________

______________________________________________________________________

The undersigned Receiver acknowledges receipt of and certifies to the Committee and 

the Secretary of Agriculture that the above tomatoes will be used for the purpose 

indicated. Falsification of information on this government document may result in a 

fine, imprisonment, or both (18 U.S.C. 1001).

RECEIVER’S NAME _________________________________________________

ADDRESS __________________________________________________________

SIGNATURE _______________________________________________________

Instructions to Receiver: Upon receipt of these forms, promptly complete the BLUE 

copy and mail to the Committee. Retain the YELLOW copy for your files. FAILURE 

TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES 

PERMITTING SHIPMENTS OF SPECIAL PURPOSE TOMATOES TO YOUR 

FIRM.

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 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.