Fillable Connecticut Department of Agriculture (State of Connecticut/Department of Administrative Services)

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Connecticut Department of Agriculture (State of Connecticut/Department of Administrative Services)

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Qualified Exemption / Not a Covered Farm Exemption
Declaration
State and federal law contain provisions that allow for some produce
growers, based on sales, certain exemptions from routine produce
safety inspection activities. To be exempted or qualified exempt because your Produce Farm
sales fall below minimum produce sales value or it meets the Qualified Exemption sales values
specified in 21 CFR Part 112.5, you may submit this signed attestation to the Connecticut
Department of Agriculture. Note: any Produce Farm may be subject to an inspection or
investigation whenever there is an allegation of adulteration or misbranding, involving produce.
By checking this box and completing the information below:
I am declaring over a three-year period, the rolling average sales of produce from my farm
are less than $25,000 (adjusted for inflation*)
I am declaring the Qualified Exemption. My produce sales exceed $25,000, my total food
sales are less than $500,000 (adjusted for inflation*) and over 50% of my sales are made
directly to qualified end users such as: the consumer of the food, restaurants or retail food
establishments, located in Connecticut or not more than 275 miles from my farm.
I am declaring that all produce sold by me receives a commercial processing that
adequately reduces the presence of microorganisms of public health significance.
The Connecticut Department of Agriculture encourages all produce farms meeting the above
requirements to submit this declaration annually.
Byaffixingmysignaturetothisdocument,Icertifythatthesubmittedinformationistrueandcompletetothebest
ofmyknowledgeandbelief.Iunderstandthatafalsestatementinthesubmittedinformationmaybepunishable
asacriminaloffenseundersection53a‐157boftheConnecticutGeneralStatutes.
Farm/Business Name
Farm/Business Address (street, city/town)
Printed Name
Signature
*CurrentInflationAdjustedValues
Connecticut Department of Agriculture
Produce Safety Program
State of Connecticut | 450 Columbus Boulevard, Suite 702 | Hartford, CT 06103 | Tel: 860-713-2522 |
Email: ProduceSafety@ct.gov
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Connecticut Department of Agriculture (State of ConnecticutDepartment of Administrative Services)

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Completed 20 July 2020

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