No Form Number ID/E.OR Receiver's Cert. of Use

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

Date: ___________________________________

RECEIVER’S CERTIFICATE OF USE

This form is required for each order placed with an Idaho-Eastern Oregon handler for potatoes not meeting Federal Marketing Order Standards, but can be used for any number of cars per order. Failure to sign and return this form to the Idaho-Eastern Oregon Potato Committee (Committee) can be deemed sufficient reason to void the handlers permit to ship potatoes for special use.

This is to certify that we have placed an order with __________________________________________________ of

Handler

__________________________________________________ for approximately __________________________of

City/State Hundredweight

Idaho-Eastern Oregon grown potatoes not graded to minimum marketing order standards for fresh market use. We further certify that said potatoes will be used for the intended purpose of ___________________________________

Processing, Charity, Research, etc.

and will not be diverted for fresh market use.

The undersigned acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above potatoes will be used for the purpose indicated. The making of a false statement, knowing it to be false, is a violation of title 18, section 1001, of the United States Code which, upon conviction, provides for a fine or imprisonment, or both.

By: _______________________________________

Title ______________________________________

Company __________________________________

Address ___________________________________

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. 01/2014. Destroy previous editions.