No Form Number (948) Application for Hardship Exemption (Area II ) (CPA

OMB No. 0581-0178

A

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

rea II Colorado Potato Administrative Committee

San Luis Valley

Office – Area II

(719) 852-4684 FAX

[email protected]

Application for

Hardship Exemption

Name _______________________________________________________ Telephone _____________________

Address ____________________________________________________________________________________

Location(s) of potatoes for hardship exemption: _____________________________________________________

Total estimated quantity of potatoes (excluding culls) produced by applicant during the current season:

Hundredweight	Variety	Grade	Size

Estimated percentage of the applicant’s potato crop (excluding culls) which cannot be shipped because applicant’s potatoes cannot meet minimum grade, size or quality regulations due to acts beyond his/her control or reasonable expectation adversely affecting his/her potatoes: ___________________________________________________________________________________________

Please explain justification for a hardship exemption: ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Quantity of potatoes already sold or shipped during the current season:

Hundredweight	Variety	Grade	Size

The undersigned certifies to the Colorado Potato Administrative Committee, USDA, and the Colorado Commissioner of Agriculture that the information provided in this application is true and correct. 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.

Signature ________________________________________________________ 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.