AFFIDAVIT
STATE OF COUNTY OF
SAMPLE NO.
55545 Shelby
Tennessee
Before me, Sidney H. Rogers , an employee of the Department of Health and Human Services, Food and Drug Administration, designated by the Secretary, under authority of the Act of January 31, 1925, 43 Statutes at Large 803; Reorganization Plan No. IV, Secs. 12-15, effective June 30, 1940; Reorganization Plan No. 1 of 1953, Secs. 1-9, effective April 11, 1953; and P.L. 96-98, Sec. 509, 93 Statutes at Large 965 (20 U.S.C. 3508), effective May 4, 1980; to administer or take oaths, affirmations, and affidavits, personally appeared George R. Applegate in the county and State aforesaid, who, being duly sworn, deposes and says:
I am manager of John's Curb Market, 342 East Johnson St., Memphis, Tennessee. As such, I have knowledge of purchasing and receipt of products at the market. On September 2, 1999, FDA Investigator Sydney H. Rogers collected from my firm a sample consisting of six - 4 pound cans of Red River Brand Pure Sorghum. This sorghum was collected from a lot of six cases, each containing 4 - 4 pound buckets (cans) purchased by me from Ted Buymore who regularly sells sorghum in this area. Ted delivered this lot of six cases to my market on August 28, 1999 in a red panel GM truck with Alabama license plates. I do not know the license number.
AFFIANT’S SIGNATURE AND TITLE
George R. Applegate, Manager
FIRM’S NAME AND ADDRESS (Include ZIP Code)
John’s Curb Market, 342 East Johnson St., Memphis, TN 38110
Subscribed and sworn to before me at
Memphis, Tennessee
this
2nd day of September 1999 .
Sidney H. Rogers
(Employee Signature) Employee of the Department of Health and Human services designated under Act of January 31, 1925, Reorganization Plan IV effective June 30, 1940; Reorganization Plan No. 1 of 1953, effective April 11, 1953; and P.L. 96-88 effective May 4, 1980.
FORM FDA 463a (4/83)
PREVIOUS EDITIONS ARE OBSOLETE
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