OMB No. 0581-0178

State of Colorado MO Docket A-4 (Exp. 3/31/2024) Destroy previous editions.

 Area II Colorado Potato Administrative Committee Experimental Exemption

 for Potatoes

 Certificate No. ________

 Date

Grower / Shipper _______________________ Receiver’s ________________________

Name & Address: _______________________ Name & Address: ________________________

_______________________ ________________________

Type of Potato: _________________________________________ Date Shipped: ___________________

Quantity Package Type Specific Variety

Trucking Company: _____________________________ Truck License Plate No: _______________________

The undersigned certifies to the Colorado Potato Administrative Committee (Committee), the United States Department of 

Agriculture, and the Colorado Commissioner of Agriculture, that these potatoes are designated for food use and/or 

quantities over 1,000 pounds will not be used for seed. The undersigned also certifies that these potatoes are of a unique 

physiological nature that makes them an experimental variety and/or for the manufacture or conversion into a specified 

product. These potatoes are exempt from grade, size, maturity, and inspection requirements prescribed under the 

Marketing Order Handling regulations for the San Luis Valley. These potatoes are subject to Marketing Order fee 

assessments as approved by the Commissioner, Colorado Department of Agriculture, and the United States Department 

of Agriculture. 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.

______________________________ ____________________________________

Authorized Shipper Signature Committee Manager, Area II

Date: ____________________________________

INSTRUCTIONS TO THE SHIPPER: Complete all portions of this Special Purpose Report for Potatoes. Sign and return 

one copy to the Committee; one copy shall accompany shipment with truck; keep one copy for your files.

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.

 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