KC-327 Dariy 6B Dairy-6 Office Forms/Price Support Cancellation Request

EXHIBIT B
March 7, 2006
See Reverse for Privacy Act, Public Burden and Nondiscrimination Statements.

KC-327 Dairy 6B

OMB Exempt

U.S. DEPARTMENT OF AGRICULTURE

(01-12-07)

Commodity Credit Corporation

DAIRY BULK CANCELLATION REQUEST FORM

MILK PRICE SUPPORT PROGRAM
CANCELLATION REQUEST
1. FROM (Company Name)

TO

FAX No. 816-926-6381
Contracting Officer
USDA-CCC-Kansas City Commodity Office
Domestic Procurement Division, Stop 8718
Dairy & Multi-Food Branch
P.O. Box 419205
Kansas City, Missouri 64141-6205

2. CITY/STATE/ZIP CODE
3. CONTACT PERSON
4a. TELEPHONE NO. (Include Area Code)

4b. EMAIL

5. Certificates to be canceled were offered under Announcement:

6. Total net quantity to be canceled:
pounds
7. Commodity

8. Pack Size

9. Reason for Cancellation

Please cancel the following certificates:
CONTRACT NUMBER

CERTIFICATE NUMBER

NOTICE TO DELIVER (N/D) NUMBER

NET WEIGHT

10.

11.

12.

13.

14a. REQUESTED BY (Signature)

14b. TITLE

14c. DATE

EXHIBIT B
March 7, 2006
See Reverse for Privacy Act, Public Burden and Nondiscrimination Statements.

KC-327 Dairy 6B (REVERSE)

OMB Exempt

U.S. DEPARTMENT OF AGRICULTURE

(01-12-07)

Commodity Credit Corportion

INSTRUCTIONS FOR DAIRY BULK CANCELLATION REQUEST FORM
1.

Specify the full company name of business canceling product.

2.

Specify the City and State of the business canceling product.

3.

Provide name of company’s contact person.

4.

Provide telephone number and email address of company contact person.

5.

Specify the Announcement under which the product was purchased (e.g., “Dairy 6”).

6.

Specify the total amount of product to be canceled.

7.

Specify the commodity type that is to be canceled.

8.

Specify the Pack size of the product that is to be canceled.

9.

Specify the reason for cancellation of the product.

10.

Specify the Contract number under which the product was purchased.
(One Contract number per page is requested.)

11.

Specify the Certificate number under which the product was purchased.

12.

Specify the Notice to Deliver number which was assigned by KCCO to Contractor.

13.

Specify the Net Weight as evidenced by each grading certificate requesting to cancel.

14.

Signature, title of person, and date submitting the request to cancel the product or the name and title of person authorized
to execute a request on behalf of the requester.
PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as
amended. The authority for requesting the following information is 7 CFR, Chapter 1430. The information will be used to accept or cancel
offers submitted by dairy processors under the milk price support program. Furnishing the requested information is voluntary. Failure to
furnish the requested information will result in nonconsideration. This information may be provided to other agencies, IRS, Department of
Justice, or other State and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The
provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be
applicable to the information provided.
The authority for collecting the following information is Public Law 107-171. This authority allows for the collection of information without prior
OMB approval mandated by the Paperwork Reduction Act of 1995. The time required to complete this information collection is estimated to
average 15 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.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin,
age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information,
political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited
bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information ( Braille,
large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of
Discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800)
795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.