PMC 4.71B CA Dried Prunes Users Certificate of Non-Human Usage of

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Form PMC 4.71B
OMB IOS81-o178

USER'S CERTIFICATE OF NON-HUMANUSAGE OF DRIED UNDERSIZED PRUNES

P-S Inspection
Certificate #

Handler

Note: To be completed and forwarded after undersized prunes have been used.

Manifest or
B/Ladine: No.

Certification:

Net Prune
Weie:ht

Date
Received

The undersigned hereby certifies to the United States Department of Agriculture and to the Prune
Marketing Committee that the above described dried undersized prunes were used for the following

purpose:

, on (date)

, at (usage

location)
Name of user firm:

Address:
Signature & Tide:

Instructions:

Date:

Complete immediately upon usaee of the described dried undersized prunes. Return the originalto the
Prune Marketing Committee, 3841North Freeway Blvd., Suite 120, Sacramento, CA 95834; PMCwill
forward a copy to your supplier;retain a copy for your records.

IMPORTANT NOTICE
This report is requiredby law (7 U.S.C. 608 (d). 7CFR §993.50,and §993.150(g) (2) (iv).
FAILURE TO REPORT can result in a fine of not less than $50.00 or more than $5.000 for each such violation and each day during which
such violation continues shall be deemed a separate violation. The issuance of a false certificate, knowing it to be false, is a violation of Title
18, Section 1001 of the United States Code, which provides a penalty of a fme of not more than $10,000, or imprisonment of not more than
5 years, or both.
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 minute per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed. and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin,
gender, religion, age, disability, political beliefS, sexual orientation, and marital or fumily status. (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 TOO).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue,
SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TOO). USDA is an equal opportunity provider and employer.