No Form No. (948) CO. Potatoes - Handler Application for Waiver of I

OMB No. 0581-0178

Colorado Potato Administrative Committee Phone: 970-352-5231

Area III - Northern Colorado Fax: 970-304-0861

P.O. Box 1774

Greeley, CO 80632

AREA III HANDLER APPLICATION FOR WAIVER OF INSPECTION

I request permission to ship potatoes under a Waiver of Inspection Privilege as established by the Committee. I agree to furnish to the Colorado Potato Administrative Committee (Committee) all information required on all shipments made under this Waiver of Inspection. The information will include the following:

• Date received

• Origin of potatoes, quantity, variety, carrier ID, purpose,

• Original inspection certificate number and date

• Receiver name, address and phone number

• Date shipped

• Quantity shipped, container size and type, carrier ID

All this required information, as well as any other information required by the Committee, will be forwarded weekly to the Committee office. Information provided is subject to verification by the Committee, the U.S. Department of Agriculture (USDA), and/or the Colorado Department of Agriculture (CDA). I agree to the following additional requirements:

1. Immediately upon receipt of this form, I will sign and return the original to the Committee, retaining the duplicate in my files.

2. As each shipment is made under this Waiver of Inspection, it will be reported on forms furnished by the Committee. The original will be returned to the Committee, and the duplicate copy will be retained in my files.

3. I certify to the Committee, the USDA, and the CDA that any shipments made on this Waiver of Inspection Privilege will be made in accordance with the marketing order.

4. I understand that failure to meet any of these requirements will result in the immediate cancellation of this Waiver of Inspection Privilege. I have received and read the marketing order regulations, and I made this application with full knowledge of the requirements.

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.

__________________________________________ _________________________________________________________

Handler Address

__________________________________________ _________________________________________________________

Authorized Representative Phone and Fax Number

____________________________________________________________________________________________________

Permission is hereby Granted/Denied the above handler to ship potatoes under a Waiver of Inspection Privilege.

__________________________________________ _________________________________________________________

Granted/Denied Date Executive Director

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 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.