KC-327 Dairy 7B DAIRY BULK CANCELLATION REQUEST FORM

EXHIBIT B
July 1, 2010
OMB Exempt

See Reverse for Privacy Act, Public Burden and Nondiscrimination Statements.

KC-327 Dairy 7B

U.S. DEPARTMENT OF AGRICULTURE

(07-01-10)

Farm Service Agency

DAIRY BULK
CANCELLATION REQUEST FORM
1. FROM (Company Name)

TO

FAX No. 816-926-6795
Contracting Officer
USDA-FSA-Commodity Operations-KC
Organization
Procurement Division, Stop 8718
Dairy and 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
See Reverse for Privacy Act, Public Burden and Nondiscrimination Statements.

KC-327 Dairy 7B (REVERSE)

July 1, 2010
OMB Exempt

U.S. DEPARTMENT OF AGRICULTURE

(07-01-10)

Commodity Credit Corporation

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 7”).

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 Commodity Operations-KC Organization 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 PAPERWORK REDUCTION ACT STATEMENTS

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). The authority for
requesting the information identified on this form is 7 CFR Part 1430, the Commodity Credit Corporation Charter Act (15 U.S.C.
714 et seq.), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246). The information will be used to request
cancellation of certificates offered to an offeror under the dairy product price support program. The information collected on this
form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that
have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses
identified in the System of Records Notice for USDA/FSA–3, Consultants File. Providing the requested information is voluntary.
However, failure to furnish the requested information will result in a determination of ineligibility for cancellation of certificates
offered to an offeror under the dairy product price support program.
The information collection is exempted from the Paperwork Reduction Act, as it is required for the administration of the Food,
Conservation and Energy Act of 2008 (see Public Law 110-246, Title I, Subtitle F – Administration).
The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program 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 toll-free at (866) 632-9992 (English) or (800) 845-6136 (Spanish) or (800) 877-8339 (TDD) or (866) 377-8642
(Federal-relay). USDA is an equal opportunity provider and employer.

NOTE: The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.