No Form number (948) CO. Potatoes (Area III) Special Purpose (other tha

Report No. ________

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

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

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 X__________________________________ ______________ 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 ultimate RECEIVER: Name ______________________________________________ Address ____________________________________________ Receiver’s Mailing Address ____________________________ (if different from above) Date Received _______________________________________ CWT Received_______________________________________ Special Purpose for which above potatoes were used: ____________________________________________________ (write 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. ____________________________________________________ Ultimate Receiver X_______________________________ _________________ 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.

*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.

*In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

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.