No Form Num. WA Potato Cmte.--Self-Reporting Potato Report

OMB No. 0581-0178

WA Assessment Reporting Form SELF-REPORTING POTATO REPORT

108 Interlake Road

Moses Lake, WA 98837

Phone: (509) 765-8845

Fax (509) 765-4853

_____________________________________________ _______________________________ ____________________

Packing Shed Name Prepared By Date

__________________________________________________________________ ______________________________________________

Street Address Signature

__________________________________________________________________

City, State, Zip Code

Packing Date	Farm/Company Name	Address, City, State	Variety*	US #1, #2, NGM	Utilization*	Total CWT Packed
* Use code number listed on Page 2				Total Per Page

Variety: (10) Russet Other

(11) Russet Norkota

(12) Ranger Russet

(13) Umatilla

(14) Burbank Russet

(15) Alturas

(16) Red

(17) Yellow

(18) White

(19) Blue/Purple

(20) Fingerlings

Utilization: (30) Table Stock

(31) Chip

(32) Dehydrated

(33) Frozen

(34) Other

Please separate out and identify grade for all varieties. A company pack out report can be used in conjunction with this submission of information.

This report is due by the 10th of the following month. Please duplicate this form if needed. Return via mail, fax or e-mail.

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.

Rev. 08/2013. Destroy previous editions.