OMB No. 0581-0178

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

 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.

 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