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Form Sc-205 - Specialty Crops Program Export Form Certificate - U.s. Department Of Agriculture

OMB No. 0581-0143

Exp. 09/30/2019

SPECIALTY CROPS PROGRAM

X-EXAMPLE

EXPORT FORM CERTIFICATE

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

COUNTRY OF

DESTINATION:

CERTIFICATE

ISSUED

APPLICANT/

CITY/STATE:

SHIPPER:

RECEIVER:

CITY/PROVINCE/

COUNTRY:

CERTIFICATE/

CARRIER ID:

WORKSHEET

NUMBER:

PLI No.:

NUMBER AND TYPE

DESCRIPTION OF PRODUCT

PRODUCT

GRADE

CWT

OF CONTAINERS

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

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:

FEE:

I, the undersigned, a duly authorized inspector of the United States Department of Agriculture, do hereby certify that samples of the

herein described product were inspected and the grades as shown by said samples were as herein stated.

OVERTIME:

EXPENSES:

INSPECTOR’S SIGNATURE

ISSUING OFFICE

ESTIMATED TOTAL

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.

SC-205 (04/17)

Form Sc-205 - Specialty Crops Program Export Form Certificate - U.s. Department Of Agriculture

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