No Form number Washington Potato Cmte. Special Purpose Shipment Report

OMB No. 0581-0178

S tate of Washington Potato Committee

P.O. Box 1815, Moses Lake, Washington 98837

Phone (509) 765-8845 / FAX (509) 765-4853

SPECIAL PURPOSE SHIPMENT REPORT ______________________

SPECIAL PURPOSE CERTIFICATE NO. _________________________

SHIPPED TO: ___________________________________________________________________________________________________

ADDRESS: ___________________________________ CITY: _____________________ STATE: ________ ZIP: ___________

VARIETY	CARRIER IDENTIFICATION - OWNER LICENSES

PURPOSE: (check one) PREPEELING   CHIPS  DEHYDRATION  CHARITY 

SALAD  FREEZING  CANNING  SEED 

EXPERIMENTATION □ ________________________________________________________

HUNDREDWEIGHT SHIPPED ________________________________ HUNDREDWEIGHT RECEIVED ___________________

DATE SHIPPED ________________________________________ DATE RECEIVED _______________________________

Is the Receiver the Processor? __________________ If not, who? ______________ Are you the Processor? _______________________

If not, who?

Name _____________________________________________ Name __________________________________________

Address ___________________________________________ Address ________________________________________

If purpose is other than stated by Shipper, specify: _______________________________________________________________________

The undersigned certifies to the Committee and the Secretary of Agriculture that these potatoes are being shipped in accordance with current Marketing Order Regulations for use only for the purpose stated. 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, among other statutes which provide for fine and imprisonment. SHIPPER’S NAME _____________________________________ ADDRESS ____________________________________________ SIGNATURE __________________________________________	The undersigned acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above potatoes will be used for the purposes 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, among other statutes which provide for fine and imprisonment RECEIVER’S NAME ____________________________________ ADDRESS ____________________________________________ SIGNATURE __________________________________________
Instruction to Shipper: Fill out this report for each Special Purpose Shipment. Sign all five copies. Mail the original (white) copy to the State Committee Office. Second copy (green) must accompany the shipment. Forward the yellow and pink copies to the receiver. Retain the gold copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES.	Instruction to Receiver: Upon receipt of these forms, promptly complete the Yellow copy and mail to the State Committee office. Retain the pink copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES PERMITTING SHIPMENTS OF SPECIAL PURPOSE POTATOES TO YOUR FIRM.

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 9 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, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Rev. 10/2010. Destroy previous editions.