Designation of Persons Authorized to Sign Handler Report

Form Approved, OMB 0581-0032

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAM

XXX Federal Milk Order XXX
Address: XXX

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 Program
XXX Federal Milk Order XXX
Address: XXX
Phone: XXX
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 15 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the
Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 202509410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English
Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and
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