PMC 4.9 CA Dried Prunes Affidavit of Diversion

OMB No. 0581-0178

PRUNE MARKETING COMMITTEE

3840 Rosin Court, Suite 170

Sacramento, CA 95834

AFFIDAVIT OF DIVERSION

STATE OF CALIFORNIA

COUNTY OF ______________________________________

The undersigned being first duly sworn deposes and says:

That the following prunes were purchased from____________________________________________ by ___________________________________________; that on or before _________________, 20___, said prunes were used for ___________________________________________________; and that he is duly authorized to make this affidavit on behalf of said Buyer.

PMC Invoice No.	Seller’s Contact or Invoice Number	Pounds	Date Received

Subscribed and sworn to before me, this ______ day of __________________________, 20___.

Signature: ___________________________________ Title: ______________________________________

Firm: ________________________________________________________________________________________

Notary Public in and for said County and State: _______________________________________________________

DIVERSION CERTIFICATE

The undersigned hereby certifies to the Prune Marketing Committee and the United States Department of Agriculture that the prunes described in the above affidavit were sold by the undersigned to the above named diverter pursuant to Prune Reserve/Surplus Tonnage Sales Agreement, form PMC 4.2, No. ____________________.

Signature: ___________________________________ Date: ______________________________________

Title: _______________________________________ Firm: ______________________________________

INSTRUCTIONS: The AFFIDAVIT OF DIVERSION must be signed by the person responsible for actually using the prunes described. The tabulated information on the AFFIDAVIT OF DIVERSION must describe the deliveries pursuant to contracts between the actual user and the firm from which he purchased. The DIVERSION CERTIFICATE must be filled out by the intermediate party between the actual diverter and the PRUNE MARKETING COMMITTEE.

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 4.9 (Rev. 01/2014. Destroy previous editions.)