J-3 Annual Allotment Certificate, Class 3

OMB No. 0581-0178

FAR WEST SPEARMINT OIL ADMINISTRATIVE COMMITTEE

100 N. Fruitland, Suite B

Kennewick, WA 99336

Phone: (509) 585-5460; Fax: (509) 585-2671

CLASS THREE BASE CERTIFICATE

Far West Spearmint Oil Administrative Committee

The CLASS THREE (NATIVE) BASE as of __________________________, 20___ for

is established at ___________ lbs. ____________________ effective.

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

ANNUAL ALLOTMENT CERTIFICATE

CLASS 3

DATE ____/____/____ _______________________ By _____________________ _______

N Name of HANDLER or, Signature of HANDLER

A if DEFICIENCY, Other GROWER or Committee Agent

T

I The making of a false certification, knowing it to be false, to an agency of the U.S. is a violation of title 18, section

V 1001, of the U.S. Code, which provides for a penalty of a fine, or imprisonment of not more than five years, or both.

E

Balance _________________

WHITE – Committee Office YELLOW – Attached to Purchase Voucher PINK – Handler

DATE ____/____/____ _______________________ By _____________________ _______

N Name of HANDLER or, Signature of HANDLER

A if DEFICIENCY, Other GROWER or Committee Agent

T

I The making of a false certification, knowing it to be false, to an agency of the U.S. is a violation of title 18, section

V 1001, of the U.S. Code, which provides for a penalty of a fine, or imprisonment of not more than five years, or both.

E

Balance _________________

WHITE – Committee Office YELLOW – Attached to Purchase Voucher PINK – Handler

DATE ____/____/____ _______________________ By _____________________ _______

N Name of HANDLER or, Signature of HANDLER

A if DEFICIENCY, Other GROWER or Committee Agent

T

I The making of a false certification, knowing it to be false, to an agency of the U.S. is a violation of title 18, section

V 1001, of the U.S. Code, which provides for a penalty of a fine, or imprisonment of not more than five years, or both.

E

Balance _________________

WHITE – Committee Office YELLOW – Attached to Purchase Voucher PINK – Handler

DATE ____/____/____ _______________________ By _____________________ _______

N Name of HANDLER or, Signature of HANDLER

A if DEFICIENCY, Other GROWER or Committee Agent

T

I The making of a false certification, knowing it to be false, to an agency of the U.S. is a violation of title 18, section

V 1001, of the U.S. Code, which provides for a penalty of a fine, or imprisonment of not more than five years, or both.

E

Balance _________________

WHITE – Committee Office YELLOW – Attached to Purchase Voucher PINK – Handler

DATE ____/____/____ _______________________ By _____________________ _______

N Name of HANDLER or, Signature of HANDLER

A if DEFICIENCY, Other GROWER or Committee Agent

T

I The making of a false certification, knowing it to be false, to an agency of the U.S. is a violation of title 18, section

V 1001, of the U.S. Code, which provides for a penalty of a fine, or imprisonment of not more than five years, or both.

E

Balance _________________

WHITE – Committee Office YELLOW – Attached to Purchase Voucher PINK – Handler

Form J-3 (Rev. 01/2014. Destroy previous editions.)