No Form Number Application for Hardship Exemption (Area II ) (CPAC 2)

OMB No. 0581-0178

Colorado Potato Administrative Committee

A

San Luis Valley

Office – Area II

(719) 852-4684 FAX

[email protected]

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

pplication for

Hardship Exemption

___________________________________________________________________________________________

Name _______________________________________________________ Telephone _____________________

Address ____________________________________________________________________________________

Location(s) of potatoes for hardship exemption: _____________________________________________________

Total estimated quantity of potatoes (excluding culls) produced by applicant during the current season:

Hundredweight	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:

Hundredweight	Variety	Grade	Size

The undersigned certifies to the Colorado Potato Administrative Committee, USDA, and the Colorado Commissioner of Agriculture that the information provided in this application is true and correct. False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

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 0581-0178.  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 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.

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