Record of Dumped Milk and Accidental Loss

Form Approved,
OMB No. 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, GA 30043
(770) 682-2501 Fax (770) 822-1038
www.fmmatlanta.com
email: [email protected]

RECORD OF MILK PRODUCTS DUMPED OR LOST
Instructions: To qualify for appropriate credit for dumped or lost product, notification must be made to the
Market Administrator’s office by telephone, fax, or email by the next business day. Please report dump
or loss to one of the phone numbers, fax numbers or email addresses listed above.

HANDLER NAME

LOCATION
(CITY/STATE)

DATE OF DUMP/LOSS

Where and how was product disposed?

TIME

(Please check description, explain if necessary)
Product dumped from batch tank, vat, silo or other measurable method.
Explain :

Product loss was not contained (accidental loss, quantity estimated through other methods).
Explain :

Product Description

Units of
Measure

Product Weight

Butterfat %

Butterfat Pounds

Handler Comments:

Handler Representative:
Name:

Date:

MA Representative Receiving Notification:
Name:
Comments:

MA Use Only
Date:

Month
Auditor
Date