PMC 4.7 CA Dried Prunes Converters Certificate of Dried Prunes f

OMB No. 0581-0178

PRUNE MARKETING COMMITTEE

3840 Rosin Court, Suite 170

Sacramento, CA 95834

CONVERTERS’S CERTIFICATE OF DRIED PRUNES FOR NON-HUMAN USAGE

Certificate No.: ___________________________________

Warehouse Release	Manifest No.	Manifest Weight	Name of Trucker	Date Received	Tractor License No.	Trailer License No.

CONVERTER’S CERTIFICATE OF NON-HUMAN USAGE OF DRIED PRUNES

The undersigned hereby certifies to the United States Department of Agriculture and to the Prune Marketing Committee (Committee) that the above described prunes were used for animal feed or were ground with other feed materials to produce animal feed on before ____________________, 20___ at the following location.

Location of feeding area or feed mill:

Name of firm: _________________________________________________________________________________

Address: _____________________________________________________________________________________

Signature: ____________________________________ Title: ______________________________________

Date: ________________________________________

INSTRUCTIONS: Execute in triplicate, completing all entries for which you have data and send the original and one copy to the Committee. Be sure the date of certification is on or after the date shown for completing the certificate.

IMPORTANT NOTICE: 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 4.7 (Rev. 01/2014. Destroy previous versions.)