Debtor:
Name of Claimant:
Contact Information of Claimant
Address for Payment to Claimant:
The following statements are true and correct:
1. I file this Declaration and declare under penalty of perjury that the following are true statements and that the attached documents are true and correct copies or original documents, which are submitted to support Claimant’s PACA claim as a beneficiary of the trust created against the above-mentioned debtor pursuant to the Perishable Agricultural Commodities Act (“PACA”), 7 U.S.C. § 499a, et. seq. and the Code of Federal Regulations implementing the PACA promulgated by the Secretary of the United States Department of Agriculture (“USDA”), 7 C.F.R. § 46.46, and I am authorized to make this Declaration and am competent to testify before the Court, if necessary, regarding the statements made in this Declaration.
2. The Claimant is / is not licensed by the USDA—PACA.
3. The Claimant's PACA license number is:
4. The sales transactions between Claimant and Debtor were based on the following payment term:
True and accurate copies of the written agreement, if any, providing for such payment terms are attached to this PACA Proof of Claim.
5. Claimant sold perishable agricultural commodities (hereinafter “produce”) on credit to Debtor as described in the below PACA Trust Chart. In each instance, the produce was received and accepted by Debtor and no adjustments have been made on the invoice amount except as listed.
6. In the PACA Trust Chart, “Invoice Number” refers to the number under which the commodity was sold to Debtor. “Date of Acceptance (or Invoice or Shipment)” refers to the date which begins the payment term between the parties. (For example, if the payment term is the regulatory ten (10) days from acceptance terms, the date would be the date the produce was accepted by Debtor; if the payment term is a written twenty-one (21) days from shipment, the date would be the date of shipment.) “Payment Due Date” refers to the date payment was due based upon the payment terms between parties. “Date Notice Given” refers to the date Claimant’s Notice of Intent to Preserve Trust Benefits (hereinafter “Trust Notice”) was given to Debtor, if applicable. “Elapsed Days” refers to the total number of days after the payment due date the Trust Notice was given to the Debtor, if applicable. “Invoice Amount Due” refers to the amount owed and remaining unpaid, whether or not it qualifies for trust protection. “PACA Trust Amount” refers to the amount owed and remaining unpaid qualifying for trust protection pursuant to the provisions of the PACA.
7. Claimant preserved its PACA trust interest against Debtor: (choose all that apply)
8. If applicable, Claimant sent Trust Notices via:
9. True and accurate copies of all unpaid invoices, Trust Notices (if applicable), and any other evidence to support Claimant’s PACA trust claim are attached.
10. The total amount of Claimant’s PACA claim is:
11. The Claimant has / has not filed any other claim against the Debtors with respect to the matters asserted in the PACA Claim:
12. The penalty for presenting a fraudulent claim is a fine of not more than Five Thousand Dollars ($5,000.00) or imprisonment for not more than five (5) years, or both. 18 U.S.C. § 152.
13. In addition to the attachments mentioned above, Claimant is attaching the following documents in support of this PACA Proof of Claim
Click below to attach documentation, including but not limited to a PACA Trust Chart (see instructions) .
Name and Title of Person Signing this PACA Proof of Claim on behalf of Claimant
I declare under the penalty of perjury, under the laws of the United States of America that the foregoing is true and correct based on my personal knowledge.
Executed on 4/16/2026