No Form Number (945) ID/E.OR Receiver's Cert. of Use

OMB No. 0581-0178

IDAHO-EASTERN OREGON POTATO COMMITTEE

3670 South 25^th Street East

Idaho Falls, Idaho 83404

Phone: (208) 529-8057/Fax: (866) 672-6425

Date: ___________________________________

RECEIVER’S CERTIFICATE OF USE

This form is required for each order placed with an Idaho-Eastern Oregon handler for potatoes not meeting Federal Marketing Order Standards, but can be used for any number of cars per order. Failure to sign and return this form to the Idaho-Eastern Oregon Potato Committee (Committee) can be deemed sufficient reason to void the handlers permit to ship potatoes for special use.

This is to certify that we have placed an order with __________________________________________________ of

Handler

__________________________________________________ for approximately __________________________of

City/State Hundredweight

Idaho-Eastern Oregon grown potatoes not graded to minimum marketing order standards for fresh market use. We further certify that said potatoes will be used for the intended purpose of ___________________________________

Processing, Charity, Research, etc.

and will not be diverted for fresh market use.

The undersigned acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above potatoes will be used for the purpose indicated. The making of a false statement, knowing it to be false, is a violation of title 18, section 1001, of the United States Code which, upon conviction, provides for a fine or imprisonment, or both.

By: _______________________________________

Title ______________________________________

Company __________________________________

Address ___________________________________

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.

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.

(Exp. x/xxxx) Destroy previous editions.