Form No. 4 Walla Sweet Onions Special Purpose Shipment Rept.

OMB No. 0581-0178

WALLA WALLA SWEET ONION MARKETING COMMITTEE

P.O. Box 644, Walla Walla, WA 99362

Phone (509) 525-1031 / Fax (509) 522-2038

SPECIAL PURPOSE SHIPMENT REPORT

Completion of this form and its submission to the Walla Walla Sweet Onion Marketing Committee (Committee) is MANDATORY if you have shipped or received Walla Walla sweet onions out of the production area under a Certificate of Privilege.

Completed by □ SHIPPER □ RECEIVER Certificate of Privilege No. ________________

Company Name _______________________________________________________________________

Contact Name _____________________________ Phone ____________ Fax ________________

Address ______________________________________________________________________________

Received From Quantity Shipped (50 lb equiv)

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________ TOTAL__________________

THE RECEIVER OF SWEET ONIONS HANDLED UNDER A CERTIFICATE OF PRIVILEGE IS RESPONSIBLE FOR THE PAYMENT OF THE COMMITTEE ASSESSMENT AT THE CURRENT RATE OF $ ____ PER 50 LB. EQUIVALENT. PLEASE ENCLOSE A CHECK OR MONEY ORDER PAYABLE TO THE “WALLA WALLA SWEET ONION MARKETING COMMITTEE” FOR: $______________.

The enclosed check/money order is payment in full for assessments owed for all shipments of Walla Walla sweet onions handled under the Certificate of Privilege during the 20____ - 20____ marketing year.

Signature ______________________________________ Date ____________________________

This form must be completed and returned, along with any assessment due, to the Committee within 30 days of the date of last shipment.

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 20 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.

Form 4 (Rev. 01/2014) Destroy previous editions.