Form FDACS-07057 "Grower Complaint Form" - Florida

Form FDACS-07057 is a Florida Department of Agriculture and Consumer Services form also known as the "Grower Complaint Form". The latest edition of the form was released in August 1, 2014 and is available for digital filing.

Download a PDF version of the Form FDACS-07057 down below or find it on Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-07057 "Grower Complaint Form" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Fruit and Vegetables
COMPLAINT FORM
ADAM H. PUTNAM
Citrus License and Bond
COMMISSIONER
170 Century Blvd. Bartow, Florida 33830
(863) 578-1900 Fax (863) 578-1901
USE THIS FORM ONLY IF YOU ARE THE GROWER OR A GROWERS COOPERATIVE
FOR THE CITRUS PRODUCT(S) INVOLVED:
1.
Complaint:
________________________________
d/b/a
____________________________________
(Grower/Co-op)
(Individual, Partner, Corp., Co-op)
2.
Mailing Address:
___________________________________________________________________
Street
City
State
Zip
Telephone
3. Respondent:
______________________________
d/b/a
____________________________________
(Dealer)
(Individual, Partner, Corp., Co-op)
4. Mailing Address:
____________________________________________________________________
Street
City
State
Zip
Telephone
5. Co-Respondent:
______________________________________
, as Surety for Respondent.
(Surety)
6. Address:
__________________________________________________________________________
Street
City
State
Zip
Telephone
7. STATE OF
___________________
8. COUNTY OF
F _________________
9.
Before me, personally appeared
________________________________________
for Complainant who being duly sworn, deposes and says that the
Respondent named above is justly indebted to said Complainant for Florida-grown citrus products described below by said Complainant and sold to said
Respondent during the 20___-20___citrus shipping season. During that season, the dealer failed to truly and correctly account for citrus product(s) and make
full payment properly therefore to the undersigned as required by Section 601.64 (4), Florida Statues. Complainant further certifies that they are the
producers of the citrus product(s) being complained of herein.
FDACS-07057 Rev. 08/14
Page 1 of 3
Florida Department of Agriculture and Consumer Services
Division of Fruit and Vegetables
COMPLAINT FORM
ADAM H. PUTNAM
Citrus License and Bond
COMMISSIONER
170 Century Blvd. Bartow, Florida 33830
(863) 578-1900 Fax (863) 578-1901
USE THIS FORM ONLY IF YOU ARE THE GROWER OR A GROWERS COOPERATIVE
FOR THE CITRUS PRODUCT(S) INVOLVED:
1.
Complaint:
________________________________
d/b/a
____________________________________
(Grower/Co-op)
(Individual, Partner, Corp., Co-op)
2.
Mailing Address:
___________________________________________________________________
Street
City
State
Zip
Telephone
3. Respondent:
______________________________
d/b/a
____________________________________
(Dealer)
(Individual, Partner, Corp., Co-op)
4. Mailing Address:
____________________________________________________________________
Street
City
State
Zip
Telephone
5. Co-Respondent:
______________________________________
, as Surety for Respondent.
(Surety)
6. Address:
__________________________________________________________________________
Street
City
State
Zip
Telephone
7. STATE OF
___________________
8. COUNTY OF
F _________________
9.
Before me, personally appeared
________________________________________
for Complainant who being duly sworn, deposes and says that the
Respondent named above is justly indebted to said Complainant for Florida-grown citrus products described below by said Complainant and sold to said
Respondent during the 20___-20___citrus shipping season. During that season, the dealer failed to truly and correctly account for citrus product(s) and make
full payment properly therefore to the undersigned as required by Section 601.64 (4), Florida Statues. Complainant further certifies that they are the
producers of the citrus product(s) being complained of herein.
FDACS-07057 Rev. 08/14
Page 1 of 3
THIS SPACE INTENTIONALLY LEFT BLANK
10. No. of Boxes
Variety
Price (Box/Lb.)
Total
__________
Grapefruit
@
$
__________
$_
______________
__________
Oranges
@
$
__________
$_
______________
__________
@
$
__________
$_
______________
TOTAL PURCHASE PRICE
$_
______________
LESS HARVESTING, MUTUAL, TAXES, ETC.
$_
______________
LESS AMOUNT RECEIVED
$_
______________
NET AMOUNT OF CLAIM (BALANCE NOW DUE)
$_
______________
11. The citrus product(s) described herein was produced on citrus groves owned
by
__________________________
, located in
_______________________
County, Florida.
12. Complainant was ___ (or) was not ___ a licensed citrus fruit dealer during the season, and the citrus
in question was ___ (or) was not ___ grown or produced on citrus groves owned or controlled by the
Complainant.
13. There was a written/oral (Please circle only one) contract entered into between the Complainant and
the Respondent on
_______
, 20. If a written contract was executed, a copy of same is attached. If no
written contract was entered, a separate writing attached to this complaint sets forth a summary of the
terms of the oral contract between the parties.
14. The citrus described in Item (11) herein, for which Complainant’s claim is being made, was harvested
during the period beginning
__________
, 20__, and ending
____________
, 20__.
15. Please make a statement outlining the various steps in the transaction(s), including efforts of
complainant to reach a settlement.
FDACS-07057 Rev. 08/14
Page 2 of 3
(CONTINUE ON SEPARATE PAGE IF NECESSARY)
16. In support of this complaint, hereto attached is the following documentary evidence:
Invoices__ Trip Tickets__ Inspection Certificates__ Manifests__ Shipping Order__ Other__
17. I, the undersigned, hereby attest that the Complainant does_____does not
______
have any civil
litigation pending against the Respondent involving the citrus product(s) complained of herein
which would preclude the Department from processing this complaint. To my knowledge, the
Respondent is_____ is not_____ involved in a bankruptcy proceeding.
18. Respondent:
______________________________
d/b/a
____________________________________
.
(Complainant, Individual, Partners, Corp., Co-op.)
19.
BY:
__________________________________
(Individual, Partner, Officer)
TITLE:
________________________________
(Owner or Officer of Corp.)
20. Sworn to and subscribed before me
(
) Personally Known
this___ day of
__________
, 20___.
( ) Produced Identification
___________________________
TYPE:
________________
Notary Public
My Commission Expires:
Important Note: In order to process your complaint and disburse funds pursuant to Section 601.66,
Florida Statutes, the State of Florida, Department of Financial Services has advised us that a Taxpayer
Identification Number is required. Please fill out the attached W-9, Request for Taxpayer Identification
Number and Certification and return it with your complaint form. Mail your completed submission to:
Florida Department of Agriculture and Consumer Services
Division of Fruit and Vegetables
Office of Citrus License and Bond
170 Century Blvd.
Bartow, FL 33830
FDACS-07057 Rev. 08/14
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