SC-205-1 (04/17) 

OMB No. 0581-0143

Exp. 09/30/2019

SPECIALTY CROPS PROGRAM

EXPORT FORM CERTIFICATE X-EXAMPLE 

(Under a Documented Quality Assurance System)

NOTICE TO APPLICANT/SHIPPER: APPLES and GRAPES: This certificate must accompany export shipments and be presented to the U.S. Customs and Border Protection 

Service (CBP). Electronically scanned version must be submitted with entry documents to CBP’s Automated Commercial Environment (ACE) system. If the original does not 

accompany shipment and is not loaded to CBP’s ACE system, the shipment may be denied exit from U.S. Commerce or placed under detention. 

SHIPMENTS to CANADA: The original of this certificate must accompany regulated shipments and be presented to Canada Customs for entry. If the original does not accompany 

shipment, the shipment may be denied entry or placed under detention for failure to comply with Agriculture Canada’s Fresh Fruit and Vegetable Regulations.

WARNING: Any person who knowingly shall falsely make, issue, alter, forge, or counterfeit this certificate, or participate in any such actions, is subject to a fine of not more than 

$1,000 or imprisonment for not more than one year, or both.

DATE M M D D Y Y IDENTIFICATION 

CERTIFICATE NUMBER:

ISSUED

CONTRACTED 

COMPANY: 

CITY/STATE:

RECEIVER: CITY/PROVINCE/

COUNTRY:

CERTIFICATE/ 

WORKSHEET 

NUMBER:

CARRIER ID:

PLI No.: 

PRODUCT NUMBER AND TYPE 

OF CONTAINERS

DESCRIPTION OF PRODUCT 

(BRAND, VARIETY, SIZE, ORIGIN, ETC.) GRADE

THIS IS TO CERTIFY THAT THE ABOVE IDENTIFIED LOT(S) MEET THE REQUIREMENTS OF THE:

 EXPORT APPLE ACT EXPORT GRAPE AND PLUM ACT EXPORT GRAPE AND PLUM ACT except for export to destinations in Europe, Greenland or Japan

 CANADIAN IMPORT REQUIREMENTS OF SECTION 35 (1) OF AGRICULTURE CANADA’S FRESH FRUIT AND VEGETABLE REGULATIONS 

OR REQUIREMENTS OF MINISTERIAL EXEMPTION (EASEMENT) ISSUED BY AGRICULTURE CANADA AS FOLLOWS:

CONTRACT No.: WITH AMENDMENT

REMARKS:

The product described above was packed in 

accordance with a Documented Quality 

Assurance System contract between the 

packer and the USDA. The packer is 

regularly audited by the USDA to determine 

compliance with such contract.

I, the undersigned, a duly authorized representative of the contracted company noted above, do hereby certify that the above 

described product was packed in accordance with a valid Documented Quality Assurance System contract between the contracted 

company and the USDA and meets all specified requirements.

REPRESENTATIVE’S SIGNATURE

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 is 0581-0143. The time required to complete this information collection is estimated to average 5 

minutes per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the 

collection of information. 

EXAMPLE
SC-205-1 (04/17) 

Non-Discrimination Policy: 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.

EXAMPLE