No Form number ID/E. OR Potatoes Receivers Certificate of Use

OMS No. 0581-0178

Mail to:
P.O. Box 2192

IDAHO-EASTERN OREGON POTATO COMMITTEE
Administering
Federal Marketing Order No. 945
1775 E. 17th Street
Idaho Falls, Idaho 83403
Phone: (208) 529-8057
Fax: (208) 529-8057
Date:
RECEIVER'S CERTIFICATE OF USE
This is to certify that we have placed an order with
of

for approximately
(City/State)

(Handler)

of Idaho-Eastern Oregon grown potatoes not graded
(Hundredweight)

to minimum marketing order standards for fresh market use. We further certify that
said potatoes will be used for the intended purpose of
(Processing, Charity, Research, etc.)

and will not be diverted for fresh market use.
The undersigned acknowledges receipt of and certifies to the
Committee and the Secretary of Agriculture that the above potatoes will
be used for the purpose indicated. I realize that the making of a false
statement, knowing it to be false, is a violation of Title 18, Section 1001, of
the United States Code which, upon conviction, provides for a fine or
imprisonment, or both.
BY:
TITLE:
COMPANY:

ADDRESS:
This form is required for each order placed with an Idaho-Eastern Oregon handler for potatoes
not meeting Federal Marketing Order Standards, but can be used for any number of cars per
order. Failure to sign and return this form to the Committee can be deemed sufficient reason to
void handlers permit to ship potatoes for special use.
According to the Paperwork

Reduction Act of 1gg5, en agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMS control number.
The valid OMS control number far this information collection is 0581'{)178.
The time required to complete this information collection is
estimated to average 5 minutes per response, including the time far nNiewing instructions,
searching existing data sources, gathering and maintaining
the data needed, and
completing
and reviewing the collection of information.

The U.S. Deparlment of Agriculture (USDA) prohibit$ discrimination
in all it$ programs and activities on the basis of ~
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 from eny public essistance program (Not all prohibifsd bases apply to all programs.)
Persons with disabilities
who require alternative means far
communication
of program information (Breille, Ia1pe print audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice end TDD).

To file a complaint
(voice)

or (202)

of discrimination, write to USDA, Direcror, Office of Civil Rights, 1400 Independence

720-$382

(TOO). USDA

is an equal

opportunity

prrYIIider and employer.

Avenue, S. W., Washington, D.C. 20250-gt/1G, or call (BOO) 7g5-3272