No Form number (948) Colorado Potatoes (Area III) (Chipping Potatoes)

COLORADO POTATO ADMINISTRATIVE COMMITTEE NORTHERN COLORADO AREA III P.O. Box 1774 Greeley, CO 80632 (970) 352-5231/ FAX (970) 304-0861

OMB# 0581-0178 Federal Marketing Order 948 State of Colorado MO docket A-4 Exp. x/xxxx. Destroy previous editions

Special Purpose Report For Chipping Potatoes

Purchase Order or Load No.

I/We

(Name of Firm or Individual)

located at

(Complete Business or Street Address)

has shipped to

(Name of Firm or Individual)

At

(Complete Business or Street Address)

Receiver’s Mailing Address

(If different from above)

Date of Shipment

Hundredweight of Chipping Potatoes Shipped

Variety of Chipping Potatoes

Truck License Plate Number

Business Address

The undersigned certifies to the Committee, the Colorado Commissioner of Agriculture, and the Secretary of Agriculture that these potatoes are being diverted from fresh channels in accordance with the regulations of the Colorado Potato Administrative Committee Area III.

X

Authorized Signature Date

INSTRUCTIONS TO THE SHIPPER: Fill out this report for each Special Purpose Shipment of Chipping Potatoes. Sign all three copies. Return the original (WHITE) copy to the Committee Office. Forward the BLUE copy with the truck and keep the YELLOW copy for your files.

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 OMB 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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Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender