POT-SHR Designated Seed Handler's Report for Potato Research & P

DESIGNATED HANDLER’S REPORT FOR POTATO RESEARCH AND PROMOTION ACT - SEED
Name:_________________________________ Company:______________________________ Address:_______________________________ ______________________________________ _______________________________	OMB #0581-0093 US POTATO BOARD MAIL TO: XXXXXXXX City, State Zip INSTRUCTIONS: Mail original and duplicate copy to N.P.P.B. together with full remittance. Must be mailed within 10 days after the end of each month during which potatoes were handled. ◄ PLEASE COMPLETE
PERIOD COVERED BY THIS REPORT:
DATE OF LAST REPORT:

FOR ADDITIONAL SPACE, YOU MAY ATTACH YOUR OWN SEPARATE SHEETS. For questions about completing this report call (xxx) xxx-xxxx

SECTION 1:

1.) LIST HERE THE CWT OF POTATOES SOLD AS SEED: ____________________

Assessment of $0.xxx per cwt is due with this report x .XXX

T OTAL AMOUNT OF ASSESSMENTS DUE:

SECTION 2:

1. LIST HERE THE CWT OF POTATOES SOLD TO OTHER HANDLERS (Packers or Processors):

List each handler’s name and address along with the corresponding cwt. These are potatoes on which the assessments have been reported and remitted to the Board by the purchaser on your behalf. You may include seed brokers in this section as long as they have deducted the assessment from your sale and remitted payment to the Board on your behalf. Sales to seed brokers on which you report and remit assessments must be included in Section 1.

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CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.xx per cwt on all potatoes listed in section 1 handled during this reporting period for which I am required to pay the assessments as the first handler. The assessments on the cwt. reported in section 2 have been reported and remitted by others for my account. I will submit verification of the above upon request.

TAX ID___________________________

SIGNATURE

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TITLE

This report is required by law [7 U.S.C. 2619, 7 CFR 1207.350, 7 CFR 1207.512 and 7 CFR 1207.513(c)]. Failure to report can result in a fine of not less than $750 or more than $7,500 for each such violation. Each such violation shall be deemed a separate violation. The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, Section 1001 United States Code, which provides for the penalty of a fine of $10,000 or imprisonment of not more than five years, or both.

POT-SHR (09/07)

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is the Potato Research and Promotion Act (7 U.S.C. 2611-2627). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) is mandatory, and will be used to determine affiliation or entity identity.

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 0581-0093. The time required to complete this information collection is estimated to average 30 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.

POT-SHR (09/07)