DA-15-CG Application for Initial or Continued Qualification

Attachment A (Page 1 of 2)

Approved OMB No. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE DAIRY PROGRAMS APPLICATION FOR INITIAL OR CONTINUED QUALIFICATION OF NATIONAL, REGIONAL OR STATE DAIRY PRODUCT PROMOTION, RESEARCH, OR NUTRITION EDUCATION PROGRAM (Under Dairy Production Stabilization Act of 1983)	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 0581-0093. The time required to complete this information collection is estimated to average 3 hours 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, 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 USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410, USA, or call (800)795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
USDA, AMS, DAIRY PROGRAMS PROMOTION AND RESEARCH BRANCH STOP 0233, ROOM 2958-S 1400 INDEPENDENCE AVENUE, SW WASHINGTON, D.C. 20250-0233	Information is collected in order to determine initial or continued qualification of dairy product promotion, research or nutrition education programs (7 CFR 1150.153). Application is voluntary but qualification is necessary to receive a benefit. Information from organizations is held confidential in the manner set forth in 7 CFR 1150.173, except for any release required under the Freedom of Information Act.
The Dairy Promotion and Research Order (7 CFR 1150.101 et seq.) provides in §1150.153 that any organization that conducts a National, regional or State dairy product promotion, research, or nutrition education program may request qualification of its program from the Secretary of Agriculture. Producers or importers contributing to a qualified program (QP) may receive credit for contributions to such program pursuant to §1150.152 of the Order. To be eligible for initial or continued qualification, the program must: a. Be engaged in dairy product promotion, research, or nutrition education that are intended to increase consumption of milk and dairy products generally. b. Except for programs operated under the laws of the United States or any State, and except for importer programs, have been active and ongoing before November 29, 1983. c. Be financed primarily by producers, either individually or through cooperative associations, and/or for importer programs, be financed primarily by importers. d. Not use a brand or trade name in its advertising and promotion of dairy products unless approved by the National Dairy Promotion and Research Board and the Secretary. e. Certify to the Secretary that any requests from producers or importers for refunds under its programs will be honored by forwarding to the Board or to the qualified State or regional program designated by the producer or importer that portion of the refund equal to the amount of the credit given to the producer or importer because of his/her participation in the program. The amount of such credit may not exceed 10 cents per hundredweight for a producer and 2.5 cents per hundredweight or equivalent thereof, for an importer. f. Not use program funds for the purpose of influencing governmental policy or action. If additional space is required, provide an additional attachment identified by item number. The following information is to be submitted by each organization requesting initial or continued qualification of its National, regional or State dairy product promotion, research, or nutrition education program(s).
1. CURRENT NAME AND ADDRESS OF ORGANIZATION (Complete Mailing Address) Name: ________________________________________________________ Telephone No.: __________________________________________ Add1: ________________________________________________________ Fax Number: ___________________________________________ Add2: ________________________________________________________ Email Address: _________________________________________ City: ____________________________ State: ________ Zip: __________
2. DOES YOUR ORGANIZATION CONDUCT OR FUND A DAIRY PRODUCT: (Answer All That Apply) A. Promotion Program? B. Research Program? C. Nutrition Education Program?
3. IS YOUR ORGANIZATION PRIMARILY FINANCED (50% OR MORE) DIRECTLY BY PRODUCERS, COOPERATIVE ASSOCIATIONS AND/OR IMPORTERS? Yes No		4. ARE CONTRIBUTIONS BY PRODUCERS OR IMPORTERS REFUNDABLE TO SUCH PRODUCERS OR IMPORTERS? Yes No
5. DOES YOUR PROGRAM UTILIZE A BRAND OR TRADE NAME IN ITS ADVERTISING AND PROMOTION OF DAIRY PRODUCTS? Yes No
7. IF YOUR PROGRAM OPERATES UNDER STATE LAW, WHAT IS THE MANDATORY ASSESSMENT RATE PER HUNDREDWEIGHT UNDER THAT PROGRAM? PLEASE LIST THE AMOUNT OF THE STATE ASSESSMENT OR N/A (NOT APPLICABLE). CENTS PER HUNDREDWEIGHT

FORM DA-15-CG (2/11) (Destroy all previous editions)

8. PROVIDE THE FOLLOWING INFORMATION ON ANNUAL INCOME AND EXPENDITURES FOR THE CALENDAR YEAR ENDING _________

(SEE ACCOMPANYING ADDITIONAL INSTRUCTIONS FOR FORM DA-15-CG.) (YEAR)

SOURCES OF TOTAL ANNUAL INCOME:

Carryover from Previous Year (This should be the same as last year's reported "Total Funds

Available for Future Year Programs.") $

Current Year Income ^1/

Producer/Importer Remittances

Add: Payments Received from Other QPs +

Add: Payments Received from Unified Marketing Plan Equalization Fund +

Less: Payments Transferred to Other QPs (-)

Less: Payments Transferred to Unified Marketing Plan Equalization Fund (-)

Other Income Sources^2/

TOTAL ADJUSTED ANNUAL INCOME^3/

EXPENDITURES:^4/ (Provide total expenditures spent directly by your organization for each line item)

Advertising, Promotion, and Sales (AP&S)

Fluid Milk

Cheese

Butter

Imported Dairy Products

Frozen Dairy Products

Other AP&S Expenditures^5/

Subtotal for AP&S

Nutrition Education

Nutrition Research

Dairy Product Research

Market and Economic Research

Public and Industry Communications

Unified Marketing Plan^6/

Administrative^7/

Other Expenditures^8/

TOTAL ANNUAL EXPENDITURES

UDIA DUES^9/

TOTAL ANNUAL EXPENDITURES AND UDIA DUES

TOTAL FUNDS AVAILABLE FOR FUTURE YEAR PROGRAMS^10/ $

1/ Please provide a schedule of income for all sources of current year income. List each separate source and amount of income by name of remitter. DO NOT list individual producers or importers. List funds received from and/or transferred to each QP and for the Unified Marketing Plan Equalization Fund separately.

2/ Examples of Other Income Sources include: total interest earned by your organization; income from processors, handlers, sales of supplies and materials; refunds from overpaid expenditures; contributions from various organizations; gains on the sale of property and equipment; and miscellaneous items. These items should be listed separately on the attached schedule of income.

3/ Total Adjusted Annual Income equals the total of all Sources of Income minus Payments Transferred to Other QPs and/or the Unified Marketing Plan Equalization Fund.

4/ For each line item expenditure, enclose a schedule of expenses by project or program area, including a project description(s) and related costs. If no funds were spent in a line item, indicate zero (-0-).

5/ Examples of Other AP&S Expenditures include calcium, nonfat dry milk, holiday, and multi-product advertising and promotion programs.

6/ Please enclose a copy of your unified marketing plan expenditure reports and supplemental documentation.

7/ Section 1150.151 (a) of the Order states that the administrative expenses incurred by the National Dairy Board shall not exceed 5 percent of the projected revenue of that fiscal year. In this regard, we urge you to keep the administrative expenses of your organization to a minimum.

8/ Examples of Other Expenditures include capital expenses, contributions to universities and other organizations, etc. Provide a schedule of expenditures.

9/ Report only UDIA membership dues.

10/ Total Funds Available for Future Year Programs equals Total Annual Expenditures and UDIA dues subtracted from Total Adjusted Annual Income.

9. PROVIDE YOUR ANNUAL AUDIT, INCLUDING THE AUDITOR'S LETTER OF COMMENTS THAT ADDRESSES THE FIVE CRITERIA (ITEMS A-E) FOUND ON PAGE 3 OF THE ACCOMPANYING ADDITIONAL INSTRUCTIONS FOR FORM DA-15-CG.

10. PROVIDE A COPY OF YOUR MOST RECENT ANNUAL REPORT.

I hereby certify that the information provided above is true, complete, and correct to the best of my knowledge. If producers or importers are eligible to receive a refund of their contributions, I also certify that the producer’s or importer’s refund requests will be handled in accordance with the Order. The Secretary of Agriculture may examine our books, records, files, and facilities to verify any of the information submitted and may procure other information to verify this organization's eligibility for qualification. I agree to notify the Dairy Programs, AMS, of any changes in our organizational structure, including merger or other types of consolidation; changes that may affect our program's continued qualification (see items 2 through 6); or if our program is discontinued.
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_{FORM DA-15-CG (2/11) (Reverse)}