SPECIAL PURPOSE SHIPMENT REPORT FOR POTATOES OTHER THAN FOR CHIPPING

To be completed by SHIPPER:

Shipped to __________________________________________

Address ____________________________________________

Date of Shipment _____________________________________

CWT & Variety Shipped _______________________________

Intended Use ________________________________________

Trucking Co. Name ___________________________________

Truck License No. ____________________________________

The undersigned certifies to the Committee, Colorado Department of 

Agriculture, and U.S. Department of Agriculture that these potatoes 

are being diverted from fresh channels in accordance with 

marketing order regulations. 

____________________________________________________

Shipper

X__________________________________ ______________

Authorized Signature Date

INSTRUCTIONS TO SHIPPER: Fill out this report for each Special 

Purpose Shipment. Sign all four copies. Mail the original (WHITE) 

copy to the Committee Office. Forward the BLUE and YELLOW

copies to the receiver. Keep the PINK copy for your files.

FAILURE TO COMPLY WILL RESULT IN 

CANCELLATION OF CERTIFICATE OF PRIVILEGE.

To be completed by ultimate RECEIVER:

Name ______________________________________________

Address ____________________________________________

Receiver’s Mailing Address ____________________________

(if different from above)

Date Received _______________________________________

CWT Received_______________________________________

Special Purpose for which above potatoes were used:

____________________________________________________

(write type of use)

The undersigned acknowledges receipt of and certifies to the 

Committee, Colorado Department of Agriculture, and U.S. 

Department of Agriculture that these potatoes are being diverted 

from fresh channels in accordance with marketing order regulations. 

____________________________________________________

Ultimate Receiver

X_______________________________ _________________

Authorized Signature Date

INSTRUCTIONS TO ULTIMATE RECEIVER: Upon receipt of these 

forms, promptly complete the BLUE copy and mail to the Committee 

Office. Retain the YELLOW copy for your files.

FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF

CERTIFICATES PERMITTING SHIPMENTS OF POTATOES 

FOR SPECIAL PURPOSES TO YOUR FIRM.

 

TO BE FULLY COMPLETED AND FILED BY BOTH THE SHIPPER AND RECEIVER

Brokers and/or sales agents are not to be construed as eligible receivers of potatoes for processing.

*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. 

Report No. ________ COLORADO POTATO ADMINISTRATIVE COMMITTEE

NORTHERN COLORADO OFFICE AREA III

P.O.Box 1774, Greeley, CO 80632

Phone (970) 352-5231/ FAX (970) 352-5231

OMB # 0581-0178

Federal Marketing Order 948

State of Colorado MO Docket A-4

Exp. 3/31/2024. Destroy previous

editions