PMC 4.71B CA Dried Prunes Users Certificate of Non-Human Usage of

OMB No. 0581-0178

PRUNE MARKETING COMMITTEE

3840 Rosin Court, Suite 170

Sacramento, CA 95834

USER'S CERTIFICATE OF NON-HUMAN USAGE OF DRIED UNDERSIZED PRUNES

P-S Inspection

Certificate No.: _________________________________ Handler: ___________________________________

Note: To be completed and forwarded after undersized prunes have been used.

Manifest or B/Lading No.

Net Prune Weight

Prunes to be Used for

Name of Trucking Co.

Date Received

Tractor License No.

Trailer License No.

CERTIFICATION: The undersigned hereby certifies to the United States Department of Agriculture and to the Prune Marketing Committee (Committee) that the above-described dried undersized prunes were used for the following purpose, _______________________________ on __________________, 20___, at (usage location) _____________________________________________________________________.

Name of user firm: _________________________________________________________

Address____________________________________________________________________

Date: _____________________________________________________________________

Signature & Title: ___________________________________ Date: ________________

INSTRUCTIONS: Complete immediately upon usage of the described dried undersized prunes. Return the original to the Committee. The Committee will forward a copy to your supplier. Also retain a copy for your records.

IMPORTANT NOTICE: This report is required by law (7 U.S.C. 608(d). 7CFR 993.50, 993.150(g)(2)(iv).

FAILURE TO REPORT can result in a fine for each such violation and each day during which such violation continues shall be deemed a separate violation. 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.

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 4.71B (Rev. 01/2014. Destroy previous editions.)