No Form No. CO. Potatoes - Handler Application for Waiver of Inspect

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

HANDLER APPLICATION FOR WAIVER OF INSPECTION

I request permission to ship potatoes under a Waiver of Inspection Privilege as established by the Committee. I agree to furnish to the Colorado Potato Administrative Committee (Committee) all information required on all shipments made under this Waiver of Inspection. The information will include the following:

• Date received

• Origin of potatoes, quantity, variety, carrier ID, purpose,

• Original inspection certificate number and date

• Receiver name, address and phone number

• Date shipped

• Quantity shipped, container size and type, carrier ID

All this required information, as well as any other information required by the Committee, will be forwarded weekly to the Committee office. Information provided is subject to verification by the Committee, the U.S. Department of Agriculture (USDA), and/or the Colorado Department of Agriculture (CDA). I agree to the following additional requirements:

1. Immediately upon receipt of this form, I will sign and return the original to the Committee, retaining the duplicate in my files.

2. As each shipment is made under this Waiver of Inspection, it will be reported on forms furnished by the Committee. The original will be returned to the Committee, and the duplicate copy will be retained in my files.

3. I certify to the Committee, the USDA, and the CDA that any shipments made on this Waiver of Inspection Privilege will be made in accordance with the marketing order.

4. I understand that failure to meet any of these requirements will result in the immediate cancellation of this Waiver of Inspection Privilege. I have received and read the marketing order regulations, and I made this application with full knowledge of the requirements.

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.

__________________________________________ _________________________________________________________

Handler Address

__________________________________________ _________________________________________________________

Authorized Representative Phone and Fax Number

____________________________________________________________________________________________________

Permission is hereby Granted/Denied the above handler to ship potatoes under a Waiver of Inspection Privilege.

__________________________________________ _________________________________________________________

Granted/Denied Date Executive Director

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 USDAA's TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write 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.)