OMB No. 0581-0189 

CDGAC-3 (Exp. 01/31/2027. Destroy previous editions.) 

CALIFORNIA DESERT GRAPE ADMINISTRATIVE COMMITTEE

PO Box 1269

Indio, CA 92202 

Phone: (760) 342-4385 

Fax: (760) 200-9101

Email: Admin@CaliforniaDesertGrapes.com

END-OF-SEASON SHIPMENT REPORT

____________________________________________________________________________________________ 

Handler Address City, State, Zip Code

____________________________________________________________________________________________ 

Grower Address City, State, Zip Code

Reporting Period: ______________________________________________________________________________ 

 Date of First Shipment to Date of Last Shipment

Please list all grape shipments Total Number of Lugs Shipped by Lug 

Weight 

Invoice

Number

Shipping

Date

Variety

Name

Destination

City, State

10 

lbs

12 

lbs

15 

lbs

16 

lbs

18 

lbs

20 

lbs

(Insert additional lines, if needed) Totals

The undersigned declares under penalty of perjury that the foregoing is true and correct.

____________________________________________________________________________________________________________________________________________________________ 

Handler Name Handler Signature Date

The making of a false statement or representation on this form, knowing it to be false, is a violation of Title 18, section 1001 of 

the United States Code, which provides for a penalty of a fine or imprisonment, or both. This report is required by law. (7 

U.S.C. 608(d)) Failure to report can result in a fine for each such violation, and each day during which such violation continues 

shall be deemed a separate violation.

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 OMB 

0581-0189. The time required to complete this information collection is estimated to average 30 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.
OMB No. 0581-0189

CDGAC-3 (Exp. 01/31/2027. Destroy previous editions.)

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.