DA-20 Dairy--Monthly Report & Remittance of Amount Due for all

Information is required by 7 CFR 1150.171. Failure to report can result in a fine. Information is held confidential (7 CFR 1150.173). Approved OMB No. 0581-0093

NATIONAL DAIRY PROMOTION AND RESEARCH BOARD

MONTHLY REPORT AND REMITTANCE OF AMOUNT DUE

FOR ALL MILK MARKETED COMMERCIALLY

BY PRODUCERS

(Under Dairy and Tobacco Adjustment 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 30 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.

FAILURE TO REPORT OR REMIT AMOUNT DUE CAN RESULT IN A $1,000 FINE.

ID Number

Name

Address

R eport of amount due on milk marketed by producers during Month Year

1 . Milk from producers lbs.

2 . Milk From own production (Exclude raw milk sold to other plants) lbs.

3 . Total of lines 1 and 2 lbs.

4. Gross amount due for marketings during the month (line 3 x $.0015)

(The rate of $.0015 per pound is equal to 15 cents per hundredweight.) $

5. Deduct contributions – up to $.0010 x pounds from line 3 – made to

qualified State or regional dairy product promotion programs.

If you enter an amount, complete the form on the reverse side

of the blue copy of this report. $

6 . Net amount due for marketings during the month (line 4 minus line 5) $

7 . Add or subtract adjustments for prior months (Explain) $

8 . Amount remitted with this report (line 6 plus or minus line 7) $

The report and a check payable to the National Dairy Promotion and Research Board or NDPRB in the amount shown on line 8 must be mailed by the last day of the month after the month in which the milk was marketed to:

National Dairy Promotion and Research Board

35092 Eagle Way

Chicago, IL 60678-1350

I declare under the penalties provided by law, that this report has been examined by me and to the best of my knowledge and belief is a true and complete report. I also certify that I am authorized to sign this report.

D ATE RESPONDING OFFICIAL’S NAME (Print)

T ITLE (Print) SIGNATURE

F orm DA-20 (06/07) Note: For inquiries regarding your assessment account, please telephone (847) 803-9794.

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 or call (800) 795-3272 (voice) or 202‑720-6382 (TDD). USDA is an equal opportunity provider and employer.

MAIL THIS COPY WITH YOUR REMITTANCE

On the form below¹, record the name of each qualified State or regional dairy product promotion program to which you made contributions and the amount paid to each such organization for the month that this report represents.

DO NOT LIST AMOUNTS PAID TO THE NDPRB.

NAME OF QUALIFIED PROMOTION PROGRAM	AMOUNT CONTRIBUTED	PROGRAM CODE (For NDPRB use only)
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_____________________	$_____________	__________
_____________________	$_____________	__________

“The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat.1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) is mandatory, and will be used to determine affiliation or entity identification”.

1 You may attach a separate listing or computer printout showing the above information if you prefer.