No Form number CO. Potatoes Spec. Purpose (Area II) Experimentation Exe

OMB #581-0178
Federal Marketing Order 948
State of Colorado MO Docket A-4

Certificate #
EXPERIMENTATION

EXEMPTION FOR POTATOES

COLORADO POT ATO ADMINISTRATIVE COMMITTEE, AREA II
P.O. BOX 348
MONTE VISTA, CO 81144
Phone (719) 852-3322 Fax (719) 852-4684
Grower/Shipper Name and Address:
Grower/Shipper Name
Address
City, State, and Zip Code
Receiver Name and Address:
Receiver Name
Address
City, State, and Zip Code
Type of Potato:
Specific Variety:
Quantity:
Package Type:
Date of Shipment:
Trucking Company:
Truck License Plate Number:
The undersigned certifies to the Colorado Potato Administrative Conunittee, the United States Department of Agriculture, and the
Colorado Conunissioner of Agriculture, that these potatoes are designated for food use and/or quantities over 1,000 pounds will not be
used for seed The undersigned also certifies that these potatoes are of a unique physiological nature that makes them an experimental
variety and/or for the manufacture or conversion into a specified product. These potatoes are exempt from grade, size, maturity, and
inspection requirements prescribed under the Marketing Order Handling regulations for the San Luis Valley. These potatoes are
subject to Marketing Order fee assessments as approved by the Conunissioner, Colorado Department of Agriculture, and the United
States Department of Agriculture.

Authorized Shipper Signature/Date

CPAC, Area ll, Manager/Date

INSTRUCTIONS TO THE SHIPPER: Complete all portions of this Special Purpose Report
for Potatoes. Sign and return one copy to the CPAC office, one copy shall accompany shipment
with truck, and keep one copy for your files.
According to the Paperwwk 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 9 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. The U.S. Department of Agriculture (USDA) prohibits discrimination in all
its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial
status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an
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disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should
contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA,
Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or
(202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.