POT-FHR Designated First Handler's Report for Potato Research &

OMB No. 0581-0093

DESIGNATED HANDLER REPORT
(Handler Name) (Street Address) (City, State Zip)	MAIL TO: Potatoes USA XXXX P.O. Box XXXX State, City, Zip
PERIOD COVERED BY THIS REPORT:	DATE OF LAST REPORT:
INSTRUCTIONS: Mail original to Potatoes USA together with the full remittance. The Designated Handler Report must be mailed within 10 days after the end of each month during which potatoes were handled. All cwt listed must be rounded to two decimal places. For additional space, you may attach your own separate sheet(s). For questions about completing this report call (xxx) xxx-xxxx.
SECTION 1: CWT OF YOUR OWN PRODUCTION OF POTATOES SOLD: CWT OF POTATOES PURCHASED FROM GROWERS (LIST TOTAL BY STATE) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ SECTION 1 Total cwt: Total Assessments Due (cwt x $0.xx):		_______________ _______________ _______________ _______________ _______________ _______________ _______________ $_______________
SECTION 2: CWT OF POTATOES PURCHASED FROM OTHER HANDLERS, BROKERS, OR PACKERS: List each handler’s name, address, and corresponding cwt. These are potatoes purchased on which the assessment has been paid by the supplier. ________________________________________________________________ ________________ ________________________________________________________________ ________________ ________________________________________________________________ ________________ ________________________________________________________________ ________________ CWT OF POTATOES YOU HAVE SOLD TO OTHER HANDLERS List each handler’s name, address, and corresponding cwt. These are potatoes purchased on which the assessment has been paid by the supplier. ________________________________________________________________ ________________
CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge. The included 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.
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Signature Date

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 $1,257 or more than $12,570 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, §1001 United States Code, which provides for the penalty of a fine of $10,000, imprisonment of not more than 5 years, or both.

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 were 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 SW., 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-FHR (Expiration Date XX/XX/20XX) See reverse for burden/non-discrimination statements