No Form number Colorado Potatoes (Area III) (Chipping Potatoes)

OMB No. 0581-0178

Colorado Potato Administrative Committee Phone: 970-352-5231

Area III - Northern Colorado Fax: 970-304-0861

P.O. Box 1774

Greeley, CO 80632

Special Purpose Report For Chipping Potatoes

Purchase Order or Load No. ________________________________________________________________________

I/We ____________________________________________________________________________________________

(Name of Firm or Individual)

located at ________________________________________________________________________________________

(Complete Business or Street Address)

has shipped to ___________________________________________________________________________________

(Name of Firm or Individual)

at ______________________________________________________________________________________________

(Complete Business or Street Address)

Receiver’s Mailing Address _________________________________________________________________________

(If different from above)

Date of Shipment _________________________________________________________________________________

Hundredweight of Chipping Potatoes Shipped _________________________________________________________

Variety of Chipping Potatoes ________________________________________________________________________

Truck License Plate Number ________________________________________________________________________

Business Address ________________________________________________________________________________

The undersigned certifies to the Colorado Potato Administrative Committee (Committee), the Colorado Commissioner of Agriculture, and the Secretary of Agriculture that these potatoes are being diverted from fresh channels in accordance with the Committee regulations.

_________________________________________________ ______________________________________

Authorized Signature Date

INSTRUCTIONS TO THE SHIPPER: Fill out this report for each Special Purpose Shipment of Chipping Potatoes. Sign all three copies. Return the original (WHITE) copy to the Committee. Forward the BLUE copy with the truck and keep the YELLOW copy for your files.

False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statutes, which provide for a fine, imprisonment, or both.

Report No._______________________

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 0581-0178. The time required to complete this information is estimated to average 9 minutes per response, including the time for reviewing instructions, searching existing data 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 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, 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.

State of Colorado MO Docket A-4 (Rev. 01/2014. Destroy previous editions.)