No Form number Oregon-California Potato Cmte. Special Purpose Shipment

OMB NO. 0581-0178

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

Oregon-California Potato Committee
700 NE Multnomah, Ste. 460, Portland, OR 97232-4104
Questions? Call (503) 731-3300

SPECIAL PURPOSE SHIPMENT

REPORT

INSTRUCTIONS
Handlers complete all information below your column for all potatoes delivered to the same receiver. For the column - Delivery Information, please indicate a Railroad Car Number, Truck
License. Following delivery to the receiver, make a copy of this report for the receiver and promptly return the original to the Committee. If you are performing as a handler and receiver, please
complete both sections and send completed original to the Committee within 15 days of shipment. Receivers - complete all information below your column and make a copy of this report for the
handler and promptly return the original to the Committee. The undersigned certifies to the Committee and the Secretary of Agriculture that the following potatoes are being diverted from fresh
channels in accordance with the regulations of the Oregon-California Potato Committee. Falsification of information on this government document may result in a fine of not more than $10,000 or
imprisonment of not more than five (5) years, or both (18 U.S.C. 1001). Failure to comply will result in cancellation of certificate.

-

ULTIMATE RECEIVER INFORMATION

HANDLER INFORMATION
Business Name

I

Business Name
Full Address

Phone(s)

I

I

Phone(s)

Certificateof Privilege No.

I

State PotatoesGrown

Signature
Date of
Shipment

I

I

Full Address

Delivery Information

Inspection
Certificate Number

TOTAL

I

I

Date
Hundredweight
ShiDDed

T

I Date I

Signature

Date Potatoes
Received

Type of Use

Hundredweight Received

TOTAL

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 ofinformation 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 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, age, disability, and where applicable, sex, marital status, familial
status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived !Tomany 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 Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice)
or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
(12/06)