ATTACHMENT_2_AOC.pdf

ATTACHMENT 2

BLM - RSW SEED BUY

NON-CERTIFIED WILDLAND COLLECTED OR NON-CERTIFIED CULTIVATED SEED

SPECIES/AREA OF ORIGIN CLAIMED (AOC) STATEMENT

NOTE: Attachment 2 shall be provided for all non-certified wildland collected or non-certified germplasm cultivated seed. Items identified with letter designator AOC in the schedule. This form is to be used only for non-certified germplasm seed – required at time of delivery.

I hereby claim that the seed collected was from _________________________ species.

Origin Information: (where the seed is growing).*

State: _________________________________________

County: _________________________________________

Elevation: _________________________________________

Latitude: _________________________________________

Longitude: _________________________________________

*If seed is cultivated, provide State, County, Elevation, Lat/Long and Lot Number for both the original claimed geographic site of the seed and where the cultivation site is located.

Seed Collector Signature Date

Seed Collector Name: __________________________________

Address: __________________________________

City/State/Zip __________________________________ Phone: _____________

Email address: __________________________________

This collected seed was sold to: __________________________________

Name and Address of Buyer: ____________________________________________________

Signature (Buyer) Date

The penalty for making false statements, relating to this statement, is as prescribed in 18U.S.C.1001, which states in part: A(a) Except as otherwise provided in this section, whoever, in any manner within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully – (1) falsifies, conceals, or covers up by a trick, scheme, or device a material fact; (2) makes any materially false, fictitious or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any material false, fictitious, or fraudulent statement or entry; shall be fined under this title or imprisoned not more than 5 years or both.