Monthly Report of Payments Received by Coop. Association

Form Approved, OMB 0581-0032

United States Department of Agriculture
Agricultural Marketing Service
Dairy Program

Mailing Address

XXX Federal Milk Order XXX

XXX
XXX

XXX
Phone:
XXX
Fax:
E-mail: XXX
Home Page: XXX

MONTHLY REPORT OF PAYMENTS RECEIVED BY COOPERATIVE ASSOCIATION FROM HANDLERS
COOPERATIVE ASSOCIATION:

MONTH:

ORDER:

This report is required by the order in accordance with 7 U.S.C. 609c and d. Failure to report can result in the assessment of a civil penalty
of up to $1,000 per day (7 U.S.C. 608c(14)(B)) or, upon conviction, in a fine of up to $5,000 per day (7 U.S.C. 608c (14)(A)).

Gross
Amount
Due

HANDLER
$

** If applicable

Net
Amount
Due

Adjustments
(-) or +
$

$

SECOND ADVANCE**
Date
Amount
Received

FIRST ADVANCE
Date
Amount
Received
$

$

FINAL SETTLEMENT
Date
Received
Amount
$

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

SIGNED:

TITLE:
(Person Authorized to Sign for Handier)

DATE:

USDA AMS Dairy Program
XXX Federal Milk Order XXX
Address: XXX
Phone: XXX
Monthly Report of Payments Received by Cooperative Association from Handlers

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