No Form number OR-CA Potatoes--Handler Statement Form

OMS No. 0581-0178
United Slates Department
Agricultural

Marketing

Fruit and Vegetable

Oregon-California

of Agriculture

Potato Committee

Service

700 NE Multnomah, Ste. 460, Portland, OR 972324104

Programs

(503) 731-3300; Fax: (503) 2394763

Handler Statement for Oregon-Califomia Potatoes
HANDLERS of Oregon-California potatoes, as defined by Federal Marketing Order No. 947, are required to
submit this statement, along with all assessments due, to the Committee by the 10th day of the month following
the month of purchase or sale.

Purchase
Date

Your Lot ID#

Grower's Name &Address

District

CWl

Amount

Subtotal
ApplicableLateFees
Total
_____ __u_ _ _____ __ ____ ____ __n_ ____ n. __... .__..__ ..._.. _ __..

. __ _.__._.._.

Handler Name
Address
City, State, Zip
Sianature
Print Name
Aoconling to the Pape1WorlcReduction Act of 1995, an agency may not cooduct or sponsor, and a person is not required to respond to a collection of infonnation WIless it
displays a valid OMB control nwnber. The valid OMB control nwnber for this infonnation collection is 0581-0178. The time required to complete this infonnation 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 ofinfonnation.
The U.S. Departmmt of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin. age, disability, and wh...
applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic infonnation, political beliefs, reprisal, or because all or part of an individual's
income is derived /Tom any public assistance program (Not all prohibited bases apply to all programs.) Penoons with disabilities who require alternative means for
comnllmication ofprogram infonnation (Bmil1e, huge 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, OfliceofCivil Rights, 1400 lndependmce Avmue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202)
72~382 (TDD). USDA is an equal opportunity provider and employer.

For OCPC Use Only: Date
(01107)

Check #

Amount

District