No Form number CO Potatoes (Area II) Special Purpose Shipment

COLORADO POTATO ADMINISTRATIVECOMMITTEE

SANLUISVALLEYOFFICEAREAn
P.O. BOX 348
MONTE VISTA CO 81144

OMB#0581-D178
FederalMarketingOrder948

SlateofColoradoMODocketA-4

Phone (719) 852-3322 FAX (719) 852-4684

SPECIAL PURPOSE SHIPMENT REPORT
CERTIFICATE OF PRIVILEGE NO.
This Certificate of Privilege is granted for
hundredweight of potatoes to be used for the sole
purpose of PROCESSING. Pennission is hereby granted to:
Shipper Name
Address
City, State, and Zip Code
To ship or handle potatoes in the above listed amount and for the stated purpose. The potatoes governed by

this Certificateshallbe deliveredon or before

, at whichtimethis Certificateshallbecomenull

and void.
Date Shipped,
This Certificate is issued pursuant to the application of said grantee as stated above and whose said
application states the legal receiver will be:

Receiver Name
Address
City, State, and Zip Code
Pennission is herby granted by authority of the Colorado Potato Administrative Committee, Area II.
Date of Issue:

CPAC Manager
The undersigned recipient of the potatoes governed by this Certificate does understand and agree that all
potatoes granted special privilege by the authorization of this Certificate shall be handled in such prescribed
manner and for such prescribed purpose as contained in this Certificate. The certificate must accompany
the shipment and the undersigned agrees to the provisions and stipulations of this certificate and
further agrees to receive, sign and return one copy of said certificate to the Colorado Potato
Administrative Committee, P.O. Box 348, Monte Vista, CO 81144, immediately upon receipt of said
potatoes. False or fraudulent statements are subject to rme, imprisonment, or both.
Shipper Signature
Receiver Signature
Receiving Company
Date Received
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 ofinformation unless it displays a valid OMB control number. The valid OMB conlrol number for this information
collection is 0581-0178. The time required to comple\e 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
comple\ing 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, gene\ic information, political beliefs, 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 alternative means for communication of program information (Braille, large print, audiotape, e\c.) should contact USDA's
TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write 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.