Designation of Persons Authorized to Sign Handler Report

Form Approved, OMB 0581-0032

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE DAIRY
- PROGRAMS
MARKET ADMINISTRATOR
Federal Orders 6 and 7
1550 North Brown Rd., Ste. 120,
Lawrenceville, Georgia 30043

DESIGNATION OF PERSONS AUTHORIZED TO SIGN HANDLER REPORTS

The following person or persons are hereby designated to sign report forms submitted as a handler under the
orders shown above. This designation is to be made by the owner, in the case of an individual proprietorship;
by a partner, in the case of a partnership; by an officer, in the case of a corporation; or by a trustee or receiver
who has been appointed by or with the consent of a court of law.

CHECK REPORTS
AUTHORIZED TO SIGN

AUTHORIZED NAME

TITLE

SIGNATURE

Receipt &
Utilization

Producer
Payroll

Other*

• Indicate ''all'' for any person who is designated to sign all reports.

.
OFFICIAL COMPANY NAME:

ADDRESS:
(City and State)

PARENT COMPANY:

DATE:

SIGNED:

TITLE:
(Signature of Authorizing Agent)

USDA, AMS, Dairy Programs
Market Administrator
1550 North Brown Rd., Ste. 120, Lawrenceville, GA 30043
(770) 682-2501
Designation of Persons Authorized to Sign Handler Reports

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 .5 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 to
USDA, Director, Office of Civil Rights, 1400 Independence
Avenue, S.W., Washington, D.C. 20250-9410, or call (800)
795-3272 (voice) or (202) 720-6382 (TDD). USDA is an
equal opportunity provider and employer.