No Form Number ID/E.OR Cert. of Privilege Shpmt Summary - Receiver

OMB No. 0581-0178

IDAHO-EASTERN OREGON POTATO COMMITTEE

3670 South 25^th Street East

Idaho Falls, Idaho 83404

Phone: (208) 529-8057/Fax: (866) 672-6425

CERTIFICATE OF PRIVILEGE SHIPMENT SUMMARY

Dear Receiver:

____________________________________________________ (Name of Handler) was issued a Certificate of Privilege for Special Use, grade exempt, shipments of potatoes.

Marketing Order regulations require that a report, on completion of each sales contract, be filed with the Idaho-Eastern Oregon Potato Committee (Committee). Failure to file a report may be deemed sufficient reason to be removed from the Committee’s current list of Approved Manufacturers of Potato Products.

Please complete and return the lower section of this letter. If no potatoes were received, please so indicate.

Permit Number	Receiver	Total CWT Shipped

__________________________________ _______________________________________

Date Signature

_______________________________________

Firm Name

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.

Rev. 01/2014. Destroy previous editions.