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

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 SHIPMENT REPORT FOR POTATOES OTHER THAN FOR CHIPPING

To be completed by SHIPPER: Shipped to __________________________________________ Address ____________________________________________ Date of Shipment _____________________________________ CWT & Variety Shipped _______________________________ Intended Use ________________________________________ Trucking Co. Name ___________________________________ Truck License No. ____________________________________ The undersigned certifies to the Committee, Colorado Department of Agriculture, and U.S. Department of Agriculture that these potatoes are being diverted from fresh channels in accordance with marketing order regulations. ____________________________________________________ Shipper ___________________________________ ______________ Authorized Signature Date INSTRUCTIONS TO SHIPPER: Fill out this report for each Special Purpose Shipment. Sign all four copies. Mail the original (White) copy to the Committee Office. Forward the Blue and Yellow copies to the receiver. Keep the Pink copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATE OF PRIVILEGE.

To be completed by RECEIVER: Name ______________________________________________ Address ____________________________________________ Receiver’s Mailing Address ____________________________ (if different from above) Date Received _______________________________________ CWT Received _______________________________________ Special Purpose for which above potatoes were used: ___________________________________________________ (Type of Use) The undersigned acknowledges receipt of and certifies to the Committee, Colorado Department of Agriculture, and U.S. Department of Agriculture that these potatoes are being diverted from fresh channels in accordance with marketing order regulations. ____________________________________________________ Receiver ___________________________________ ______________ Authorized Signature Date 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 CERTIFICATES PERMITTING SHIPMENTS OF POTATOES FOR SPECIAL PURPOSES TO YOUR FIRM.

TO BE FULLY COMPLETED AND FILED BY BOTH THE SHIPPER AND RECEIVER

Brokers and/or sales agents are not to be construed as eligible receivers of potatoes for processing.

Report No.__________________________

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.

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 resources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U. S. Department of Agriculture (USDA) prohibits in all its programs and activities on the basis of race, 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 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 editions.)