No Form number CO. Potatoes Spec. Purpose (Area II) Experimental Exempt

OMB No. 0581-0178

San Luis Valley

Office – Area II

(719) 852-4684 FAX

[email protected]

Colorado Potato Administrative Committee

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

Experimental Exemption

for Potatoes

Certificate No. ________

Date

__________________________________________________________________________________________

Grower / Shipper _______________________ Receiver’s ________________________

Name & Address: _______________________ Name & Address: ________________________

_______________________ ________________________

Type of Potato: _________________________________________ Date Shipped: ___________________

Quantity Package Type Specific Variety

Trucking Company: _____________________________ Truck License Plate No: _______________________

The undersigned certifies to the Colorado Potato Administrative Committee (Committee), the United States Department of Agriculture, and the Colorado Commissioner of Agriculture, that these potatoes are designated for food use and/or quantities over 1,000 pounds will not be used for seed. The undersigned also certifies that these potatoes are of a unique physiological nature that makes them an experimental variety and/or for the manufacture or conversion into a specified product. These potatoes are exempt from grade, size, maturity, and inspection requirements prescribed under the Marketing Order Handling regulations for the San Luis Valley. These potatoes are subject to Marketing Order fee assessments as approved by the Commissioner, Colorado Department of Agriculture, and the United States Department of Agriculture. 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.

______________________________ ____________________________________

Authorized Shipper Signature Committee Manager, Area II

Date: ____________________________________

INSTRUCTIONS TO THE SHIPPER: Complete all portions of this Special Purpose Report for Potatoes. Sign and return one copy to the Committee; one copy shall accompany shipment with truck; keep one copy for your files.

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.

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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.)