
CONFIDENTIAL
41101
STATE OF CALIFORNIA SEND MONTHLY REMITTANCE
DEPARTMENT OF FOOD AND AGRICULTURE [PAYABLE TO CASHIER] AND THIS FORM TO:
FVQC--STANDARDIZATION
Cashier
Department of Food and Agriculture
1220 N Street, P.O. Box 942872
Fruit and Vegetable Shipper Monthly Remittance Report/Registration Sacramento, CA 94271-2872
51-055A (Rev. 07/07)
COMPANY NAME REGISTRATION NUMBER
P.O. BOX/STREET ADDRESS AREA CODE AND TELEPHONE NUMBER
CITY, STATE, AND ZIP CODE DUE DATE: Submit on the last day of the reporting Month
(See # 7 on the reverse side of this form for penalty information)
Check this box if any of the above information has changed
(2) (3) (4)* (5)** (6)*** (7)**** (8)
# of Containers # of Containers # of Containers # of Containers # of Containers # of Containers Assessment
Shipped Shipped Valencia Oranges Navel Oranges Lemons Mandarin Citrus Amount
(@ $0.001) (@ $0.003) Shipped Shipped Shipped Shipped
(@ $0.0045) (@ $0.009) (@ $0.004) (@ $0.0045)
SUBTOTAL
NOTE: If there are no shipments to report, this form must be submitted PENALTY
indicating "No Shipments Made" or "Nothing to Report"
TOTAL
Last report for the season. Will begin reporting again in ______________________
(1)
Commodity