No Form number Southeastern Potato Cmte. Rept. of Special Purpose Shipm

SOUTHEASTERN
POTATO COMMITTEE

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EAsTvILLE.
VIRGINIA
2334--r

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No.
OMB No. 0581-0178

REPORTOF SPECIALPURPOSEPOTATOSHIPMENT
Shipped under Certificate of PrlvDege No.

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Receiver
Address

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Truckor Traa1er
No.

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, R.R. Car No.

Purpose (check):-Potato Chipping;_Canning or Freezing;-Pther
Quantity:

(specify)

Cwt.
~

1118

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._Signature _

ShippedBy

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QuantityReceived:'
118

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Date:

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INSERTFRONTCOVERBETWEENFORMSBEFOREWRITING
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According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0178. The time
required to complete this information collection is estimated to average 5 minutes per response, including the timefor reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The US. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin,
age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political
belieft, reprisal, or because all or part of an individual's income is derived [rom any public assistance program (Not all prohibited bases apply to all
programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc)
should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office
of
1400 Independence
Avenue, S. w., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (I'DD). USDA is
an Civil
equal Rights,
opportunity
provider and employer.

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