No Form number CO. Potatoes (Area III) Special Purpose (other than for

COLORADO POTATO ADMINISTRATIVE COMMITTEE
NORTHERN COLORADO OFFICE AREA III
P. O. Box 1774, Greeley, CO 80632
Phone (970) 352-5231/ Fax (970) 304-0861

Report No.

OMB# 0581-0178
Federal Marketing

Order 948

State of Colorado MO Docket A-4

SPECIAL PURPOSE SHIPMENT REPORT FOR POTATOES OTHER THAN FOR CHIPPING
To be completed by SHIPPER:

To be completed by RECEIVER:

Shipped to

Name

Address

Address

Date of Shipment

Receiver's Mailing Address

CWT&Variety Shipped

Date Received

Intended Use

CWT Received

Trucking Co. Name

Special Purpose for which above potatoes were used:

(If different from above)

Truck License No.
(Type of Use)
The undersigned cer1lfles to Ihe Committee. the Colorado Commissioner of
AgrIculture, and Ihe Secretary of Agriculture that Ihese potatoes are being
diverted from fresh In accordance with Ihe regulations of Ihe Colorado Potato
Administrative Committee Area IlL

The undersigned acknowledges recelpt of and certifies to the Committee. the
Colorado Commissioner of Agriculture, and the Secretary of Agriculture that the
above potatoes were diverted from fresh channels in accordance with the regulations
of Ihe Colorado Potato Administrative Committee Area III.

Shipper

x
Authorized Signature

Receiver
Date

x
Authorized Signature

Date

INSTRUCTIONSTO SHIPPER: Fillout this report for each
Special Purpose Shipment. Sign all fourcopies. Mailthe original
(White) copy to the Committee Office. Forwardthe Blue and
Yellowcopies to the receiver. Keep the Pink copy for your files.

INSTRUCTIONS TO ULTIMATE RECEIVER; Upon receipt of these
forms, promptly complete the BLUE copy and mail to the Committee
Office. Retain the YELLOW copy for your files.

FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF
CERTIFICATE OF PRNILEGE.

FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF
CERTIFICATES PERMITTING SHIPMENTS OF POTATOES FOR
SPECIAL PURPOSES TO YOUR FIRM.

TO BE FULLYCOMPLETED AND FILED BY BOTH THE SHIPPER AND RECEIVER
Brokers and/or sales agents are not to be construed as eUgible receivers of potatoes for processing.
False r:ertlficatlon,knowingItto be false, Is a violationof Title18,Section 1001,of the UnitedStates Code, among other statutes, which provide for a fine, Imprisonment,or both.
According to the PapelWOl'k 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 is estimated
to average 9 minutes per response, including the time for reviewing Instructions, searching existing data resources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
The U. S. Department of Agriculture (USDA) prohibits in an Its programs and activities on the basis of rece, color nation 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 disab~ities who require alternative means for communication of
program information (Brame, 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
(voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272