No Form No. OR-CA Potato - Handler Statement for OR.-CA. Potatoes

OMB No. 0581-0178

OREGON-CALIFORNIA POTATO COMMITTEE

9320 SW BARBUR BLVD., SUITE 130

PORTLAND, OREGON 97219-5405

Phone: (503) 731-3300 / Fax: (503) 239-4763

Handler Statement for Oregon-California 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 Oregon-California Potato Committee by the 10th day of the month following the month of purchase or sale.

Purchase Date	Your Lot ID No.		Grower’s Name & Address	District	Cwt.	Amount
Subtotal
Applicable Late Fees
Total
I hereby certify that this return is true and complete in compliance with USDA Regulations.
Handler Name
Address
City, State, Zip Code
Signature
Print Name

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 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 where 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, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

For OCPC Use Only

Date:

Check No.:

Amount:

District:

Rev. 10/2010. Destroy previous editions.