POT-FHR Designated First Handler's Report for Potato Research &

DESIGNATED HANDLER’S REPORT FOR POTATO RESEARCH AND PROMOTION ACT
Name: ________________________________ Company: _____________________________ Address:_______________________________ ______________________________________	OMB #0581-0093 POTATOES USA MAIL TO: address city, state zip INSTRUCTIONS: Mail original and duplicate copy to N.P.P.B. together with full remittance. Must be mailed within 10 days after the end of each month during which potatoes were handled. PLEASE COMPLETE ◄
PERIOD COVERED BY THIS REPORT:
DATE OF LAST REPORT:

FOR ADDITIONAL SPACE, YOU MAY ATTACH YOUR OWN SEPARATE SHEETS. For questions about completing this report call (xxx) xxx-xxxx

SECTION 1: This section represents all assessable potatoes including processed grade.

1.) LIST HERE THE CWT OF YOUR OWN PRODUCTION OF POTATOES SOLD: ____________________

2.) LIST HERE THE CWT OF POTATOES PURCHASED FROM GROWERS:

List the name and address of each grower along with the corresponding cwt purchased from each grower.

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TOTAL ALL CWT FROM SECTION 1. Please use the table below to break down total cwt by market segment:

Fresh	Seed	Frozen	Chip-Stock	Dehy	Other

TOTAL AMOUNT OF ASSESSMENTS DUE: ( Effective Date, 20xx, assessment of $0.xx is due with this report ) x 0.xxx

SECTION 2:

1. LIST HERE THE CWT OF POTATOES PURCHASED FROM OTHER HANDLERS, BROKERS OR REPACKERS:

List each handler’s name and address along with the corresponding cwt. These are potatoes purchased on which the assessment has already been paid by the supplier.

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2. AS THE FIRST HANDLER, LIST HERE POTATOES YOU HAVE SOLD TO OTHER HANDLERS WHO HAVE DEDUCTED THE ASSESSMENTS:

Please provide complete names and addresses and corresponding cwt. This would include processed grade sold to a processor who has deducted and remitted the assessments due.

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CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge and the attached payment represents $0.xxx per cwt on all potatoes listed in section 1 handled during this reporting period for which I am required to pay the assessments as the first handler. The assessments on the cwt. reported in section 2 have been reported and remitted by others for my account. I will submit verification of the above upon request.

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This report is required by law [7 U.S.C. 2619, 7 CFR 1207.350, 7 CFR 1207.512 and 7 CFR 1207.513(c)]. Failure to report can result in a fine of not less than $750 or more than $7,500 for each such violation. Each such violation shall be deemed a separate violation. The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, Section 1001 United States Code, which provides for the penalty of a fine of $10,000 or imprisonment of not more than five years, or both.

POT-FHR (Revised 03/17) Destroy previous editions.

NOTE: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is from the applicable commodity legislation for research and promotion programs. Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or importer identification number is mandatory and will be used to determine affiliation or entity identity.

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 0581-0093. 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

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.

POT-FHR (Revised 03/17) Destroy previous editions.