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

DESIGNATED HANDLER’S REPORT FOR POTATO RESEARCH AND PROMOTION ACT - SEED
OMB #0581-0093
Name:_________________________________
Company:______________________________
POTATOES USA
MAIL TO:
address
Address:_______________________________
city, state zip
______________________________________
_______________________________
PERIOD COVERED BY THIS REPORT:
DATE OF LAST REPORT:

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

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

TOTAL 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___________________________
__________________________________
DATE

SIGNATURE
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 (Revised 03/17) Destroy previous editions.

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 from the applicable commodity legislation for research and promotion programs.
Furnishing the requested information is necessary for the administration of this program. Submission of
Tax Identification Number (TIN) or importer identification number 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.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or
administering USDA programs are prohibited from discriminating based on race, color, national origin,
religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital
status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal
or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all
bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g.,
Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or
USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made available in languages other
than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form,
AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or
write a letter addressed to USDA and provide in the letter all of the information requested in the form. To
request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA
by: 1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400
Independence Avenue, SW Washington, D.C. 20250-9410; 2) fax: (202) 690-7442; or 3) email:
[email protected]. USDA is an equal opportunity provider, employer, and lender.

POT-SHR (Revised 03/17) Destroy previous editions.