SC-36 (958) Special Purpose Shipment Receiver Certification

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0178

IDAHO-EASTERN OREGON ONION COMMITTEE

P.O. BOX 909, PARMA, ID 83660

PHONE: 208-722-5111 FAX: 208-722-6582

SPECIAL PURPOSE SHIPMENT RECEIVER CERTIFICATION

If you plan to purchase onions grown in the Idaho-Eastern Oregon production area that do not meet fresh market requirements as stated in 7 CFR § 958.328, and intend them for canning, dehydrating, extracting, experimentation, freezing, and/or pickling, you must complete and submit this Certificate to the Idaho-Eastern Oregon Onion Committee (Committee). No shipment of onions for canning, dehydrating, extracting, experimentation, freezing, and/or pickling may be received from the Idaho-Eastern Oregon production areas unless this form is completed and returned.

CERTIFICATION STATEMENT:

I, the undersigned, hereby certify to USDA and to the Committee that all onions received at the address below from the Idaho-Eastern Oregon production area will be used for (check all that apply):

Canning Dehydrating Experimentation Extracting Freezing Pickling

I, further certify that none of these onions will be diverted to any fresh market outlet(s). In addition, I agree to submit such documents and reports to the Committee that may be requested for its auditing purposes. Falsification of information on this government document may result in a fine or imprisonment, or both (18 U.S.C. 1001).

Signature		Name
Title		Date
Processor				Phone
Address
City		State			Zip Code

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 2 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.

SC-36 (Exp. x/xxxx) Destroy previous editions.