OMB No. 0581-0189

SC-266-12 (Exp. 1/31/2027. Destroy previous editions.)

KIWIFRUIT ADMINISTRATIVE COMMITTEE

APPLICATION FOR INSPECTION

(Waiver Form)

SECTION I (To be completed by shipper)

To: (Federal-State Inspection Program)

Office

I hereby request inspection of of 

(No. & type of containers) (Variety)

of on at 

(Fruit) (Date) (Place)

between the hours of . If inspection is not available and a waiver is issued to 

cover the above-described fruit, I will certify that it will meet all requirements of the Kiwifruit 

Administrative Committee.

(Date) (Name)

(Address)

SECTION II (To be completed by the Federal-State Inspection Program)

This will acknowledge your request for inspection. Inspection cannot be performed at the time and place 

specified and you are hereby assigned waive number: WTo cover the fruit for which you requested inspection. You are reminded that you must report all 

shipments of fruit controlled by the Kiwifruit Administrative Committee, including those that move under 

waiver to the Kiwifruit Administrative Committee, 1521 “I” Street, Sacramento, CA 95814. 

 (Date) (Name)

FEDERAL-STATE INSPECTION PROGRAM

Office

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 6 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

SC-266-12 (Exp. 1/31/2027. 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.