No Form Number Application for Hardship Exemption (Area II and Area III

OMS # 0581-0178

COLORADO POTATO ADMINISRA TIVE COMMITTEE
SAN LUIS VALLEY OFFICE AREA II
P.O. BOX 348
MONTE VISTA CO 81144
Phone:(719) 852-3322
FAX: (719) 852-4684

APPLICATION FOR HARDSHIP EXEMPTION
Name

Telephone

Address
Street

State

City

Zip Code

Location(s) of potatoes for hardship exemption:
Total estimated quantity of potatoes (excluding culls) produced by applicant during the current season:

Hundredweiaht

Variety

Grade

Size

Estimated percentage of the applicant's potato crop (excluding culls) which cannot be shipped because
applicant's potatoes cannot meet minimum grade, size or quality regulations due to acts beyond his/her control
or reasonable expectation adversely affecting his/her potatoes:

Please explain justification for a hardship exemption:

Quantity of potatoes already sold or shipped during the current season:
HundredweiQht

Variety

Grade

Size

The undersigned certifies to the Committee, USDA, and the Colorado Commissioner of Agriculture that the
information provided in this application is true and correct. I realize that the making of a false statement,
knowing it to be false, is a violation of Title 18, Section 1001, of the United States Code, among other statutes,
which provide for fine and imprisonment.
Signature

Date

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-Q178. 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 individual's income
is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require altemative 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, S. W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider
and employer.

OMS # 0581-0178

COLORADO POTATO ADMINISRA TIVE COMMITTEE
NORTHERN COLORADO OFFICE AREA III
P.O. BOX 1774
GREELEY CO 80632-1774
Phone: {970} 352-5231
FAX: {970} 304-0861

APPLICATION FOR HARDSHIP EXEMPTION
Name

Telephone

Address
Street

State

City

Zip Code

Location(s) of potatoes for hardship exemption:
Total estimated quantity of potatoes (excluding culls) produced by applicant during the current season:
Hundredweiaht

Variety

Size

Grade

Estimated percentage of the applicant's potato crop (excluding culls) which cannot be shipped because
applicant's potatoes cannot meet minimum grade, size or quality regulations due to acts beyond his/her control
or reasonable expectation adversely affecting his/her potatoes:

Please explain justification for a hardship exemption:

Quantity of potatoes already sold or shipped during the current season:
Hundredweiaht

Variety

Grade

Size

The undersigned certifies to the Committee, USDA, and the Colorado Commissioner of Agriculture that the
information provided in this application is true and correct. I realize that the making of a false statement,
knowing it to be false, is a violation of Title 18, Section 1001, of the United States Code, among other statutes,
which provide for fine and imprisonment.
Signature

Date

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 ft 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 individual's income
is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require altemative 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, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider
and employer.