Payments Made to a Cooperative Association

USDA, AMS, Dairy Programs

Market Administrator
1550 North Brown Rd., Ste. 120, Lawrenceville,

GA 30043

(7701682-2501

Pavments Made to a Gooperative Association

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 0581-0032. The
time required to complete this information collection is estimated to average 0.5 hour 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the
basis of race, color, nationalorigin, age, disabilit¡r, and where applicable, sex, marital status, familialstatus,
parental status, religion, sexual orientation, political beliefs genetic information, 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, Assistant Secretary for Civil Rights, Office of
the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C.20250-9410, or
call (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800)
845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.

Form Approved, OMB 0581-0032

UNITED STATES DEPARTMENT of AGR¡CULTURE
AGRICULTURAL MARKETING SERVICE . DAIRY PROGRAMS
MARKET ADMINISTRATOR

Phone:
Fax:
E-Mail:

770-682-2501
720-A22-1039
[email protected]

Federal Orders 6 and 7
Mailinq Address
1550 North Brown Rd., Ste. 120
Lawrenceville, Georgia 30043

HomePage: fmmatlanta.com

PAYMENTS MADE TO A COOPERATIVE ASSOCIATION
Please submit a separate form for payment to each cooperative association.
COOPERATIVE ASSOCIATION

MONTH:

:

ADDRESS:

ORDER:

This report is required by the order in accordance with 7 U.S.C. 608 c and d. Failure to report can result ln the assessment of a civil
penalty of up to $1,000 Per day (7 U.S.C. W& (14) (B)) or, upon conviction, in a fine of up to $5,000 per day (7 U.S.C. 608c (1a) (A)).
Market Administrator Use Only

Product
Pounds

Butterfat
Pounds

Cwt.

Rate

Value

PRODUCER MILK - UNIFORM

TOTAL PRODUCER MILK
OTHER SOURCE RECEIPTS
GRAND TOTAL

Product
Pounds

PAYMENTS

Cwt.
Rate

Check
Number

Date

Mailed

Amount

First Advance
Second Advance**
Final

** lf Applicable

TOTAL PAYMENTS

ldeclare underthe penalties prov¡ded by law, that this report ( including any accompanying schedules and statements) has been examined by
me and to the best of my knowledge and belief is a true, correct and complete report. I also certify that I am authorized to sign this report.

HANDLER

SIGNED
(Person Author¡zed to Sign for Handier)

DATE

TITLE