No Form number CO. Potatoes (Area II) Certificate of Privilege

OMB No. 0581-0178

San Luis Valley

Office – Area II

(719) 852-4684 FAX

[email protected]

Colorado Potato Administrative Committee

C

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

ertificate of Privilege

Certificate No. _______

Date

____________________________________________________________________________

This Certificate of Privilege is granted for ____________hundredweight of potatoes to be used for the sole purpose of________________. Permission is hereby granted to:

Shipper Name ________________________________________

Address _____________________________________________

City, Sate, and Zip Code ________________________________

to ship or handle potatoes in the above listed amount and for the above stated purpose.

The potatoes governed by this Certificate shall be delivered on or before _________________, 20___, at which time this Certificate shall become null 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, Sate, and Zip Code ________________________________

Permission is hereby granted by authority of the Colorado Potato Administrative Committee, Area II (Committee). Telephone (719) 852-3322 / FAX (719) 852-4684.

Date of Issue: ___________ ___________________________________

Committee 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 Committee, P.O. Box 348, Monte Vista, CO 81144, immediately upon receipt of said potatoes. 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.

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 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, 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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

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