No Form number (948) CO. Potatoes (Area II) Certificate of Privilege

OMB No. 0581-0178

San Luis Valley

Office – Area II

(719) 852-4684 FAX

lweyers@coloradopotato.org

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

Area II Colorado Potato Administrative Committee

Certificate of Privilege

Certificate No. _______

Date

This Certificate of Privilege is granted for ____________hundredweight of potatoes to be used for the sole purpose of________________. Permission is hereby granted to:

Shipper Name ________________________________________

Address _____________________________________________

City, Sate, and Zip Code ________________________________

to ship or handle potatoes in the above listed amount and for the above stated purpose.

The potatoes governed by this Certificate shall be delivered on or before _________________, 20___, at which time this Certificate shall become null and void.

Date Shipped: _________________________

This Certificate is issued pursuant to the application of said grantee as stated above and whose said application states the legal receiver will be:

Receiver Name _______________________________________

Address _____________________________________________

City, Sate, and Zip Code ________________________________

Permission is hereby granted by authority of the Colorado Potato Administrative Committee, Area II (Committee). Telephone (719) 852-3322 / FAX (719) 852-4684.

Date of Issue: ___________ ___________________________________

Committee Manager

The undersigned recipient of the potatoes governed by this Certificate does understand and agree that all potatoes granted special privilege by the authorization of this Certificate shall be handled in such prescribed manner and for such prescribed purpose as contained in this Certificate. The Certificate must accompany the shipment and the undersigned agrees to the provisions and stipulations of this Certificate and further agrees to receive, sign and return one copy of said Certificate to the Committee, P.O. Box 348, Monte Vista, CO 81144, immediately upon receipt of said 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.

Shipper Signature: _____________________________________

Receiver Signature: _____________________________________

Receiving Company: ____________________________________

Date Received: ________________________________________

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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

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