No Form Num. (946) WA Potato Cmte.--Self-Reporting Potato Report

OMB No. 0581-0178

WA Assessment Reporting Form SELF-REPORTING POTATO REPORT

108 Interlake Road

Moses Lake, WA 98837

Phone: (509) 765-8845

Fax (509) 765-4853

_____________________________________________ _______________________________ ____________________

Packing Shed Name Prepared By Date

__________________________________________________________________ ______________________________________________

Street Address Signature

__________________________________________________________________

City, State, Zip Code

Packing Date	Farm/Company Name	Address, City, State	Variety*	US #1, #2, NGM	Utilization*	Total CWT Packed
* Use code number listed on Page 2				Total Per Page

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.

Variety: (10) Russet Other

(11) Russet Norkota

(12) Ranger Russet

(13) Umatilla

(14) Burbank Russet

(15) Alturas

(16) Red

(17) Yellow

(18) White

(19) Blue/Purple

(20) Fingerlings

Utilization: (30) Table Stock

(31) Chip

(32) Dehydrated

(33) Frozen

(34) Other

Please separate out and identify grade for all varieties. A company pack out report can be used in conjunction with this submission of information.

This report is due by the 10th of the following month. Please duplicate this form if needed. Return via mail, fax or e-mail.

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.

(Rev. 01/2017) Destroy previous editions.