OMB No. 0581-0178

F/H Form C(2) (Exp. 3/31/2024) Destroy previous editions.

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823; Fax: (503) 678-6825

FORM FOR JUSTIFICATION OF SURETIES

STATE OF _________________________)

 ) ss.

COUNTY OF _______________________)

__________________________________________________________, a surety whose name is subscribed to the 

above undertaking, being duly sworn, says that he is one of the sureties named in the forgoing undertaking and is 

worth the sum specified in said undertaking as the maximum total aggregate liability thereunder, over and above all 

his just debts and liabilities, exclusive of property exempt from execution, and that he is a resident of 

____________________________, County of __________________________, State of _____________________.

_____________________________________________

Subscribed and sworn to before me

this ______ day of _______________, 20____.

_____________________________________

Notary Public for ____________________

My commission expires _________________

STATE OF ________________________)

 ) ss.

COUNTY OF ______________________)

________________________________________________________, a surety whose name is subscribed to the 

above undertaking, being duly sworn, says that he is one of the sureties named in the forgoing undertaking and is 

worth the sum specified in said undertaking as the maximum total aggregate liability thereunder, over and above all 

his just debts and liabilities, exclusive of property exempt from execution, and that he is a resident of 

____________________________, County of __________________________, State of _____________________.

_____________________________________________

Subscribed and sworn to before me

this ______ day of ___________, 20____.

_____________________________________

Notary Public for ____________________

My commission expires _________________

No deferment of restricted obligation will be granted through bonds with sureties acceptable to the Board unless a form for 

justification of sureties is completed and received by the Board (7 U.S.C 608(d), 7 CFR 982.54 and 7 CFR 982.454).

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 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.

 

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 

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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 

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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.