PMC 4.7 (993) CA Dried Prunes Converters Certificate of Dried Pr

OMB No. 0581-0178

PRUNE MARKETING COMMITTEE

3840 Rosin Court, Suite 170

Sacramento, CA 95834

CONVERTERS’S CERTIFICATE OF DRIED PRUNES FOR NON-HUMAN USAGE

Certificate No.: ___________________________________

Warehouse Release	Manifest No.	Manifest Weight	Name of Trucker	Date Received	Tractor License No.	Trailer License No.

CONVERTER’S CERTIFICATE OF NON-HUMAN USAGE OF DRIED PRUNES

The undersigned hereby certifies to the United States Department of Agriculture and to the Prune Marketing Committee (Committee) that the above described prunes were used for animal feed or were ground with other feed materials to produce animal feed on before ____________________, 20___ at the following location.

Location of feeding area or feed mill:

Name of firm: _________________________________________________________________________________

Address: _____________________________________________________________________________________

Signature: ____________________________________ Title: ______________________________________

Date: ________________________________________

INSTRUCTIONS: Execute in triplicate, completing all entries for which you have data and send the original and one copy to the Committee. Be sure the date of certification is on or after the date shown for completing the certificate.

IMPORTANT NOTICE: The issuance of a false certificate knowing it to be false is a violation of title 18, section 1001 of the United States Code, which provides a penalty of a fine or imprisonment, or both.

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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

PMC 4.7 (Rev. 01/2017) Destroy previous versions.