PMC 4.9 (993) CA Dried Prunes Affidavit of Diversion

OMB No. 0581-0178

PRUNE MARKETING COMMITTEE

3840 Rosin Court, Suite 170

Sacramento, CA 95834

AFFIDAVIT OF DIVERSION

STATE OF CALIFORNIA

COUNTY OF ______________________________________

The undersigned being first duly sworn deposes and says:

That the following prunes were purchased from____________________________________________ by ___________________________________________; that on or before _________________, 20___, said prunes were used for ___________________________________________________; and that he is duly authorized to make this affidavit on behalf of said Buyer.

PMC Invoice No.	Seller’s Contact or Invoice Number	Pounds	Date Received

Subscribed and sworn to before me, this ______ day of __________________________, 20___.

Signature: ___________________________________ Title: ______________________________________

Firm: ________________________________________________________________________________________

Notary Public in and for said County and State: _______________________________________________________

DIVERSION CERTIFICATE

The undersigned hereby certifies to the Prune Marketing Committee and the United States Department of Agriculture that the prunes described in the above affidavit were sold by the undersigned to the above named diverter pursuant to Prune Reserve/Surplus Tonnage Sales Agreement, form PMC 4.2, No. ____________________.

Signature: ___________________________________ Date: ______________________________________

Title: _______________________________________ Firm: ______________________________________

INSTRUCTIONS: The AFFIDAVIT OF DIVERSION must be signed by the person responsible for actually using the prunes described. The tabulated information on the AFFIDAVIT OF DIVERSION must describe the deliveries pursuant to contracts between the actual user and the firm from which he purchased. The DIVERSION CERTIFICATE must be filled out by the intermediate party between the actual diverter and the PRUNE MARKETING COMMITTEE.

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 4.9 (Rev. 01/2017) Destroy previous editions.