PMC 4.5 CA Dried Prunes Certificate of Insurance Coverage

Form PMC 4.5
OMB NO. 0581-0178

CERTIFICATE OF INSURANCE COVERAGE
TO:

Date

Prune Marketing Committee
3841 North Freeway Blw., Suite 120
Sacramento, California 95834

We certify to you and to the U. S. Department of Agriculture that we are insuring all reserw pool prunes
for fire and extended coverage during the

crop year as follows:

Handler:
Location: /1
Insurable Values on Reserw Prunes:
Not less than the insurance values placed on salable prunes of like variety, grade and size held by the
undersigned from
date of receipt through July 31,

_.

Premium rate per $100 valueper annum: /1
Insurer's Name:
Address:
Description of coverage:

We certify further that this coverage in behalf of the Prune Marketing Committee will continue as long as
the above-noted prunes continue in storage as reserw pool prunes subject to Committee disposal at the
above-specified location.
Handler:
Signature:
Title:
/1 Show address of each location to which the premium rate shown applies. A separate certificate
should be prepared for each applicable premium rate. Please attach a list if more space is needed.
IMPORTANT NOTICE
The issuance of a false certificate knowing it to be false is a violation of Title 18, Section 1001 of the United Stales Code, which provides a penalty
ofa fme of not more than $10,000 or imprisonment of not more than 5 years or both.
AUTHORITY: § 993.73 of Marketing Order No. 993, as Amended,and § 993.159 (b) of the Administrative Rules and Regulations established pursuant
thereto.
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 0 MB control number for this information collection is 058 I-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 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 orfamily status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative
meansfor communication of program information (Brail/e, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice
and TDD). Tojile a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue,
SW, Washington, DC 20250-94/0 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.