No Form Number ID/E.OR Cert. of Privilege Shpmt Summary - Receiver

OMB No. 0581-0178

IDAHO-EASTERN OREGON POTATO COMMITTEE
3670 South 25th Street East
Idaho Falls, Idaho 83404
Phone: (208) 529-8057/Fax: (866) 672-6425
CERTIFICATE OF PRIVILEGE SHIPMENT SUMMARY
Dear Receiver:
____________________________________________________ (Name of Handler) was issued a Certificate
of Privilege for Special Use, grade exempt, shipments of potatoes.
Marketing Order regulations require that a report, on completion of each sales contract, be filed with the
Idaho-Eastern Oregon Potato Committee (Committee). Failure to file a report may be deemed sufficient
reason to be removed from the Committee’s current list of Approved Manufacturers of Potato Products.
Please complete and return the lower section of this letter. If no potatoes were received, please so
indicate.
Permit Number

__________________________________
Date

Receiver

Total CWT Shipped

_______________________________________
Signature
_______________________________________
Firm Name

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 10 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. 202509410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Rev. 8/2012. Destroy previous editions.