Form FS-5103 "Shell Egg Inspection Report Form" - Oklahoma

What Is Form FS-5103?

This is a legal form that was released by the Oklahoma Department of Agriculture Food and Forestry - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2007;
  • The latest edition provided by the Oklahoma Department of Agriculture Food and Forestry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FS-5103 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Agriculture Food and Forestry.

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Download Form FS-5103 "Shell Egg Inspection Report Form" - Oklahoma

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FS-5103
Rev. 2-07
OFFICE USE ONLY
O
klahoma Department of Agriculture, Food & Forestry
FOOD SAFETY DIVISION
382-$
Poultry, Egg & Organic Foods Section
RECEIPT #
P.O. Box 528804
Oklahoma City, OK 73152-8804
DATE:
PH: (405)522-5924
FAX: (405)522-1060
SHELL EGG INSPECTION REPORT
LOCATION
PHONE (
)
ADDRESS
CITY
STATE
ZIP
In accordance with OKLAHOMA EGG LAW 2 O.S. §10-81, a financial report is required on a monthly basis, I hereby
certify that the number of dozen eggs noted below were graded, packed or repacked and intended for sale to consumers
in this state.
th
Monthly reports plus remittance in full must be mailed to this Department on or before the 15
of the following month.
Failure to make full report and remittance by the date specified will result in a penalty and make your permit subject to
cancellation.
If a report is not filed and the fees are not paid within thirty (30) days of the due date, the packer shall pay a penalty of two
percent (2%) of the fees due for each additional day the fees are late. If the report is not filed and the fees are not paid
within sixty (60) days of the due date, the amount of the penalty shall be an amount equal and in addition to the amount of
the fees due.
ATTACH A SHEET DESIGNATING THE NAME AND ADDRESS OF THE
DEALER(S) FOR WHOM THE EGGS WERE PACKED OR WHOM THE EGGS
WERE SOLD OR DELIVERED.
PACKER PERMIT #
1.
Dozen eggs packed for the month & year of
X .003 = $
2. The minimum of $18.00.
X .003 = $ 18.00
3. Pay the GREATER dollar amount of line 1 or 2.
$
(DO NOT PAY BOTH LINE 1 AND 2)
I,
, the undersigned upon oath, do depose and say that I have full
knowledge of the above and foregoing statement and figures, that said statements and figures are
just correct, due and according to law; and that I am duly authorized to make this affidavit.
AUTHORIZED SIGNATURE
DATE:
MAKE CHECK PAYABLE TO THE OKLAHOMA DEPARTMENT OF AGRICULTURE, FOOD & FORESTRY
ADDRESS ENVELOPE ATTENTION: FOOD SAFETY DIVISION: POULTRY, EGG & ORGANIC
*
FS-5103
Rev. 2-07
OFFICE USE ONLY
O
klahoma Department of Agriculture, Food & Forestry
FOOD SAFETY DIVISION
382-$
Poultry, Egg & Organic Foods Section
RECEIPT #
P.O. Box 528804
Oklahoma City, OK 73152-8804
DATE:
PH: (405)522-5924
FAX: (405)522-1060
SHELL EGG INSPECTION REPORT
LOCATION
PHONE (
)
ADDRESS
CITY
STATE
ZIP
In accordance with OKLAHOMA EGG LAW 2 O.S. §10-81, a financial report is required on a monthly basis, I hereby
certify that the number of dozen eggs noted below were graded, packed or repacked and intended for sale to consumers
in this state.
th
Monthly reports plus remittance in full must be mailed to this Department on or before the 15
of the following month.
Failure to make full report and remittance by the date specified will result in a penalty and make your permit subject to
cancellation.
If a report is not filed and the fees are not paid within thirty (30) days of the due date, the packer shall pay a penalty of two
percent (2%) of the fees due for each additional day the fees are late. If the report is not filed and the fees are not paid
within sixty (60) days of the due date, the amount of the penalty shall be an amount equal and in addition to the amount of
the fees due.
ATTACH A SHEET DESIGNATING THE NAME AND ADDRESS OF THE
DEALER(S) FOR WHOM THE EGGS WERE PACKED OR WHOM THE EGGS
WERE SOLD OR DELIVERED.
PACKER PERMIT #
1.
Dozen eggs packed for the month & year of
X .003 = $
2. The minimum of $18.00.
X .003 = $ 18.00
3. Pay the GREATER dollar amount of line 1 or 2.
$
(DO NOT PAY BOTH LINE 1 AND 2)
I,
, the undersigned upon oath, do depose and say that I have full
knowledge of the above and foregoing statement and figures, that said statements and figures are
just correct, due and according to law; and that I am duly authorized to make this affidavit.
AUTHORIZED SIGNATURE
DATE:
MAKE CHECK PAYABLE TO THE OKLAHOMA DEPARTMENT OF AGRICULTURE, FOOD & FORESTRY
ADDRESS ENVELOPE ATTENTION: FOOD SAFETY DIVISION: POULTRY, EGG & ORGANIC
*