PMC 4.5 CA Dried Prunes Certificate of Insurance Coverage

OMB No. 0581-0178

CERTIFICATE OF INSURANCE COVERAGE

TO: Prune Marketing Committee Date: ___________________________

3840 Rosin Court, Suite 170

Sacramento, CA 95834

We certify to you and to the U. S. Department of Agriculture that we are insuring all reserve pool prunes for fire and extended coverage during the 20___ crop year as follows:

Handler: ________________________________________________________________

Location¹: _______________________________________________________________

Insurable Values on Reserve 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, 20___.

Premium rate per $100 value per annum¹:

Insurer’s Name and Address: _____________________________________________________________

Description of coverage: ________________________________________________________________

We certify further that this coverage in behalf of the Prune Marketing Committee (Committee) will continue as long as the above-noted prunes continue in storage as reserve pool prunes subject to Committee disposal at the above-specified location.

Handler: ___________________________________ Signature: ______________________________

Title: ______________________________________

¹ Show the 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.

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 fine or imprisonment, 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 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 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.

PMC 4.5 (Rev. 10/2010. Destroy previous editions.)