Form No. 4 (956) Walla Sweet Onions Special Purpose Shipment

OMB No. 0581-0178

WALLA WALLA SWEET ONION MARKETING COMMITTEE

6601 W. Deschutes Ave., Suite C-2

Kennewick, WA 99336

Phone: (509) 585-5460 or Fax: (509) 585-2671

SPECIAL PURPOSE SHIPMENT REPORT

Completion of this form and its submission to the Walla Walla Sweet Onion Marketing Committee (Committee) is MANDATORY if you have shipped or received Walla Walla sweet onions out of the production area under a Certificate of Privilege.

Completed by □ SHIPPER □ RECEIVER Certificate of Privilege No. ________________

Company Name _______________________________________________________________________

Contact Name _____________________________ Phone ____________ Fax ________________

Address ______________________________________________________________________________

Received From Quantity Shipped (50 lb equiv)

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________

________________________________ __________________ TOTAL__________________

THE RECEIVER OF SWEET ONIONS HANDLED UNDER A CERTIFICATE OF PRIVILEGE IS RESPONSIBLE FOR THE PAYMENT OF THE COMMITTEE ASSESSMENT AT THE CURRENT RATE OF $ ____ PER 50 LB. EQUIVALENT. PLEASE ENCLOSE A CHECK OR MONEY ORDER PAYABLE TO THE “WALLA WALLA SWEET ONION MARKETING COMMITTEE” FOR: $______________.

The enclosed check/money order is payment in full for assessments owed for all shipments of Walla Walla sweet onions handled under the Certificate of Privilege during the 20____ - 20____ marketing year.

Signature ______________________________________ Date ____________________________

This form must be completed and returned, along with any assessment due, to the Committee within 30 days of the date of last shipment.

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 20 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.

Form 4 (Exp. x/xxxx) Destroy previous editions.