OMB No. 0581-0178

PMC 4.7 (Exp. 3/31/2024) Destroy previous versions.

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.