OMB No. 0581-0125 

Exp. 10/31/2026

SPECIALTY CROPS INSPECTION DIVISION 

POSITIVE LOT IDENTIFICATION 

STAMP(S)/DIE(S) REQUEST FORM 

A. Stamp Description

Stamp Location (Applicant): Stamp Manufacturer: 

Stamp Manufacturer: Please reproduce, at the Applicant’s expense, _______ hand stamps or________ in-line coder printing dies bearing the approved USDA 

Federal-State Inspection logo with the following permanently affixed accountability number(s). 

____ Inches 

House 

Number 

District 

Number 

Inspection 

Number 

Office/Market 

Number 

B. Applicant’s Request

As a duly authorized agent of the above firm (Applicant), I hereby request that the above stamp/die order be approved and produced. I/We agree to be 

responsible for all charges assessed by the stamp manufacturer for this order. I also acknowledge that all stamps/dies ordered are the exclusive property of the 

United States Department of Agriculture and/or the___________________________________________________Federal-State Inspection Service. 

______________________________________________________ ___________________________________ 

Applicant’s Authorization Signature Date of Request 

E-Mail Address: 

C. State/District Authorization

I have reviewed the above request and give approval for the order to be processed. 

_______________________________________________________ ___________________________________ 

State/District Authorization Signature Date of Request 

D. Federal Authorization

All stamps/dies which make reference to or imply that a product has been USDA or Federal-State inspected are accountable items and are the property of the 

United States Department of Agriculture. No stamps/dies shall be produced without specific written consent of the Federal Program Manager/ Supervisor. 

________________________________________________________ ___________________________________ 

Federal Program Manager/Supervisor’s Signature Date of Authorization 

NOTE: These stamps/dies are to be 

mailed to the Federal-State District 

Supervisor who will distribute 

them. 

MAIL STAMPS/DIES TO 

E. Manufacturer’s Statement

I certify that each stamp/die produced by this firm bears a permanent accountability number and the only stamps/dies produced by this firm with markings 

referencing the USDA and/or the ______________________Federal-State Inspection Service are those that have been authorized in writing by the USDA. 

_____________________________________________ __________________________________________ _________________________________ 

Manufacturer’s Signature of Compliance Title Date of Shipment 

F. Local/District Receipt

I have received_______________ (quantity) stamp/dies bearing the following permanently affixed accountability number(s). 

____________ ____________ ____________ ____________ ____________ ____________ 

____________ ____________ ____________ ____________ ____________ ____________ 

_______________________________________________________ ___________________________________ 

District Supervisor’s Signature Date Received 

G. Authorized PIQ-PLIDS Firm Representative/Inspector’s Receipt

I have received the above listed stamps/dies and they are now my responsibility. 

_______________________________________________________ ___________________________________ 

Authorized Signature Date Received 

____ Inches 

SC-24 (1-2024) Destroy previous editions. USDA is an equal opportunity provider, employer, and lender.
 

 

 

 

 

 

 

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 0581-0125. The time required to complete this information collection is estimated to average 1 hour 

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. 

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. 

SC-24 (1-2024) Destroy previous editions. USDA is an equal opportunity provider, employer, and lender.