Combine Clean-Out Affidavit

COMBINE CLEAN-OUT AFFIDAVIT

Please complete a clean-out affidavit before harvest and for each different crop harvested. Note field numbers and date clean-out procedures were performed.

Producer Clean-Out Date ______

Crop ______Field Number ______

Custom Operator Name ______

Address ______

Type of Machine ______

Clean-out Procedure: (S) Sweeping; (C) Compressed air; (W) Washing Please mark each part of the combine that was cleaned and the procedure used.

Header Sieves and Chaffers Feederhouse Cylinder and/or Rotor Grain Tank Shoe Supply Augers Straw Walkers Unloading Auger Ledges, Frame Rails Rock Trap Clean and Return Elevators and Cross Augers

I hereby attest that the above practices and procedures have been completed in accordance with OCIA Standards.

Operator Producer

DateDate

(Attach a copy of the invoice for contracted services.) Use of this form is optional. Another form accomplishing the same purpose may be used if appropriate to your operation.