SPECIAL PURPOSE REPORT FOR CHIPPING POTATOES

Purchase Order or Load No.

I/We

(Name of Firm or Individual)

located at

(Complete Business or Street Address)

has shipped to

(Name of Firm or Individual)

At

(Complete Business or Street Address)

Receiver’s Mailing Address 

(If different from above)

Date of Shipment 

Hundredweight of Chipping Potatoes Shipped

Variety of Chipping Potatoes

Truck License Plate Number

Business Address

The undersigned certifies to the Committee, the Colorado Commissioner of Agriculture, and the Secretary of Agriculture that these potatoes are being diverted 

from fresh channels in accordance with the regulations of the Colorado Potato Administrative Committee Area III.

X

Authorized Signature Date

INSTRUCTIONS TO THE SHIPPER: Fill out this report for each Special Purpose Shipment of Chipping Potatoes. Sign all three copies. 

Return the original (WHITE) copy to the Committee Office. Forward the BLUE copy with the truck and keep the YELLOW copy for your files.

False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statutes, which provide for a fine, 

imprisonment, or both.

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

COLORADO POTATO ADMINISTRATIVE COMMITTEE 

NORTHERN COLORADO AREA III

P.O. Box 1774 

Greeley, CO 80632

(970) 352-5231/ FAX (970) 304-0861

OMB#

0581-0178 

Federal Marketing Order 948 

State of Colorado MO docket A-4

Exp. 3/31/2024. Destroy previous editions