Record of Dumped Milk and Accidental Loss

USDA, AMS, Dairy Programs

Market Administrator
1550 North Brown Rd., Ste 120,
Lawrenceville, GA 30043
17701682-2501

Record of Dumped Milk and Accidental Loss

According to the Paperwork Reduction Act of 1995, anagency 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 0581-0032.
The time required to complete this information collection is estimated to avemge .5 hours per
l€sponse, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information.
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Form Approved, OMB 0581-0032

UNITED STATES DEPARTMENT of AGRICULTURE
AGRICULTURAL MARKETING SERVICE . DAIRY PROGRAMS
MARKET ADMINISTRATOR
FederalOrders 6 and 7
1550 No¡th Brown Rd., Ste. 120, Lawrenceville, GA 30043
(7701 682-2501 Fax (770) 822-1038
www.fmmatlanta.com

Record of Dumped Milk and Accidental Loss
Handler Name:
City and State:
Order No.:

Date:

Dumped Skim and Butterfat

Accidental Loss

Was dumped product used as animalfeed ?

Yesl
¡-¡

Noll

I

Handler Statement:

Product
Description

Units
(Specify)

Product
Pounds

Butterfat
Test

---

3.

Butterfat
Pounds
%

4.

-

6.

-3

7.

%
o/o

%
o/o
o/o

10.

%

TOTALS
Reported By:

Title:
(Signature)

(Please Print Name)

ln order to receíve proper credit for dumped milk and accidental losses, this form must be faxed to the Atlanta
Market Administator office no later than the next businesss day. ln addition, adequate supporting documentation
must be maintained in order that quantities dumped, destroyed or lost can be verified by the Market Administrator.