OMB No. 0581-0178

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

 Area II Colorado Potato Administrative Committee

 Exemption for

 Fingerling 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 fingerling potatoes are designated for food use and 

will not be used for seed. 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 5 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