No Form number (948) CO Potatoes (Area II) Authorization for Special Pu

OMB No. 0581-0178

Area II Colorado Potato Administrative Committee

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

San Luis Valley

Office – Area II

(719) 852-4684 FAX

lweyers@coloradopotato.org

Authorization for

Special Purpose

Shipments

This Authorization for Special Purpose Shipments is required for the shipment of potatoes for other than fresh market purposes. Special purpose shipments include charity, prepeeling, canning, freezing, and/or “other processing.” “Other processing” includes, but is not restricted to, dehydration, chips, shoestrings, starch and flour. It includes the application of heat or cold to such an extent that the natural form or stability of the potato undergoes a substantial change. Potatoes for special purposes are exempt from the requirements of grade, size, maturity, and inspection.

By signing this form, I certify to the Colorado Potato Administrative Committee - Area II (Committee), the United States Department of Agriculture, and the Colorado Commissioner of Agriculture that any special purpose shipments made pursuant to this Authorization will be made in accordance with marketing order regulations. I have read these regulations and I certify that I shall request a Certificate of Privilege from the Committee for each load of potatoes to be shipped for special purposes. I certify that all potatoes granted a Certificate of Privilege by virtue of this Authorization must be used for the purpose stated in each Certificate of Privilege. Any deviation or infringement of this privilege will be reported to the Committee promptly. I certify that I will not knowingly sell, or cause to be sold, potatoes which have been granted a Certificate of Privilege and are to be used in violation of said Certificate of Privilege. All or any part of the Certificate of Privilege not duly executed may be recalled or revoked at the discretion of the Committee and when violation of said Application and Certificate of Privilege are in evidence. It is agreed that the Committee will be notified of any shipments rejected by receivers of special purpose potatoes. 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.

Return this form by _____________ to the Committee office.

______________________________________

Company Name

______________________________________ ______________________________________

Approved by Area II Business (or Street) Address

______________________________________ ______________________________________

Date City, State, and Zip Code

______________________________________

Mailing Address (if other than above)

______________________________________

Authorized Signature and Date

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.

State of Colorado MO Docket A-4 (Exp. x/xxxx) Destroy previous editions.