No Form number OR/CA Potatoes--Rept. of Anticipated Shipment to Receive

OMB # 0581-0178

OREGON-CALIFORNIA POTATO COMMITTEE
Marketing Order No. 947
700 NE MULTNOMAH, SUITE 460
PORTLAND, OREGON 97232
Phone: 503-731-3300
REPORT OF ANTICIPATED SHIPMENTS TO RECEIVER
NOT ON APPROVED MANUFACTURERS LIST
Fill in this form when shipping potatoes to a company this is not listed on the Oregon-California Potato
Committee's Approved Manufacturers List. Mail the completed form to the Committee.

Name of Receiver
Address
City, State, Zip
PhonelFAX

I certify that potatoes being shipped to the above name receiver will be used only for processing into
products, and not for fresh market use.

Signature
Company Name
Address
City, State, Zip
PhonelFAX

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 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 statos, familial status, parental statos, religion, sexual orientation, genetic information, political beliefs,
reprisal, or because all or part of an individual's income is derived from 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 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)