DA-15-CG Application for Initial or Continued Qualification

Approved OMB No. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAM
APPLICATION FOR INITIAL OR CONTINUED QUALIFICATION
OF DAIRY PRODUCT PROMOTION, RESEARCH,
OR NUTRITION EDUCATION PROGRAM
(Under Dairy Production Stabilization Act of 1983)

USDA, AMS, DAIRY PROGRAM
PROMOTION, RESEARCH AND PLANNING DIVISION
STOP 0233, ROOM 2958-S
1400 INDEPENDENCE AVENUE, SW
WASHINGTON, D.C. 20250-0233

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 3 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.
Information is collected in order to determine initial or continued
qualification of dairy product promotion, research or nutrition education
programs (7 CFR 1150.153). Application is voluntary but qualification is
necessary to receive a benefit. Information from organizations is held
confidential in the manner set forth in 7 CFR 1150.173, except for any
release required under the Freedom of Information Act.

The Dairy Promotion and Research Order (7 CFR 1150.101 et seq.) provides in §1150.153 that any organization that conducts a dairy product
promotion, research, or nutrition education program may request qualification of its program from the Secretary of Agriculture. Producers or
importers contributing to a qualified program (QP) may receive credit for contributions to such program pursuant to §1150.152 of the Order.
To be eligible for initial or continued qualification, the program must:
a. Be engaged in dairy product promotion, research, or nutrition education activities that are intended to increase consumption of milk and
dairy products generally.
b. Except for programs operated under the laws of the United States or any State, and except for importer programs, have been active and
ongoing before November 29, 1983.
c. Be financed primarily by producers, either individually or through cooperative associations, or for importer programs, be financed
primarily by importers.
d. Not use a brand or trade name in its advertising and promotion of dairy products unless approved by the National Dairy Promotion and
Research Board and the Secretary.
e. Certify to the Secretary that any requests from producers or importers for refunds under its programs will be honored by forwarding to the
Board or to the qualified program designated by the producer or importer that portion of the refund equal to the amount of the credit given
to the producer or importer because of his/her participation in the program. The amount of such credit may not exceed 10 cents per
hundredweight for a producer and 2.5 cents per hundredweight or equivalent thereof, for an importer.
f.

Not use program funds for the purpose of influencing governmental policy or action.

The following information is to be submitted by each organization requesting initial or continued qualification of its dairy product promotion,
research, or nutrition education program(s). If additional space is required, provide an additional attachment identified by item number.
1.

CURRENT NAME AND ADDRESS OF ORGANIZATION (COMPLETE MAILING ADDRESS):

Name:

Telephone No.:

Address:

Fax Number:

Address:

Email Address:

City:

State:

2.

DOES YOUR ORGANIZATION CONDUCT OR FUND A DAIRY PRODUCT: (CHECK ALL THAT APPLY)
A. Promotion Program?

3.

5.

B. Research Program?

IS YOUR ORGANIZATION PRIMARILY FINANCED (50% OR MORE)
DIRECTLY BY PRODUCERS, COOPERATIVE ASSOCIATIONS AND/OR
IMPORTERS?
Yes
No

4.

ARE CONTRIBUTIONS BY PRODUCERS OR IMPORTERS
REFUNDABLE TO SUCH PRODUCERS OR IMPORTERS?
Yes

No

No

DOES YOUR ORGANIZATION USE PROGRAM FUNDS FOR THE PURPOSE OF INFLUENCING GOVERNMENTAL POLICY OR ACTION?
Yes

7.

C. Nutrition Education Program?

DOES YOUR PROGRAM UTILIZE A BRAND OR TRADE NAME IN ITS ADVERTIZING AND PROMOTION OF DAIRY PRODUCTS?
Yes

6.

Zip:

No

IF YOUR PROGRAM OPERATES UNDER STATE LAW, WHAT IS THE MANDATORY ASSESSMENT RATE P ER HUNDREDWEIGHT UNDER THAT
P ROGRAM? PLEASE LIST THE AMOUNT OF THE STATE ASSESSMENT OR N/A(NOT APPLICABLE).
CENTS PER HUNDREDWEIGHT

FORM DA-15-CG (Rev. 04/17) (Destroy all previous editions)

8. PROVIDE THE FOLLOWING INFORMATION ON ANNUAL INCOME AND EXPENDITURES FOR THE CALENDAR

YEAR ENDING:
(REFERENCE THE ACCOMPANYING ADDITIONAL INSTRUCTIONS FOR FORM DA-15-CG.)

(YEAR)

SOURCES OF TOTAL ANNUAL INCOME:
CARRYOVER FROM PREVIOUS YEAR (This should be the same as last year's reported "Total Funds Available for
Future Year Programs.") .................................................................................................................................
CURRENT YEAR INCOME (Provide total income for each line item. Seperately, attach a schedule of income and/or your

$

accounting system for all sources of current year income. List each separate source and amount of income. DO NOT
list individual producers or importers. List funds received from and transferred to each QP and for the Unified
Marketing Plan Equalization Fund separately.)

PRODUCER REMITTANCES ........................................................................................................................................
ADD: PAYMENTS RECEIVED FROM OTHER QPS
.......................................................................................................
+
ADD: PAYMENTS RECEIVED FROM UNIFIED MARKETING PLAN EQUALIZATION FUND .............................................. +
SUBTRACT:
PAYMENTS TRANSFERRED TO OTHER QPS ............................................................................................ (-)
SUBTRACT:
PAYMENTS
TRANSFERRED
TO
UNIFIED
MARKETING
PLAN
EQUALIZATION
FUND
...................................
(-)
OTHER INCOME SOURCES .........................................................................................................................................
TOTAL ADJUSTED ANNUAL INCOME 8.1/ ....................................................................................................
$
EXPENDITURES:
(Provide total expenditures spent directly by your organization for each line item. Seperately, attach a schedule of expenses and/or your accounting
system reports for each expenditure category, including a project description(s) and related costs. If no funds were spent in a line item, indicate zero.)

ADVERTISING, PROMOTION, AND SALES (AP&S) EXPENDITURES FOR:
FLUID MILK AP&S .......................................................................................
CHEESE AP&S ..............................................................................................
BUTTER
AP&S
..............................................................................................
FROZEN DAIRY
PRODUCTS
AP&S
.................................................................
OTHER AND MULTI-PRODUCT AP&S EXPENDITURES .....................................
SUBTOTAL FOR AP&S..............................................................................................
NUTRITION EDUCATION EXPENDITURES ...................................................................................................................
NUTRITION RESEARCH .............................................................................................................................................
DAIRY PRODUCT RESEARCH ....................................................................................................................................
MARKET AND ECONOMIC RESEARCH .......................................................................................................................

=

PUBLIC AND INDUSTRY COMMUNICATIONS ..............................................................................................................
UNIFIED MARKETING PLAN .....................................................................................................................................
ADMINISTRATIVE 8.2/ ................................................................................................................................................
OTHER EXPENDITURES .............................................................................................................................................
TOTAL ANNUAL EXPENDITURES ................................................................................................................
UDIA MEMBERSHIP DUES (Only) ...........................................................................................................................
TOTAL ANNUAL EXPENDITURES AND UDIA DUES ..............................................................................
TOTAL FUNDS AVAILABLE FOR FUTURE YEAR PROGRAMS 8.3/ .......................................................

$

8.1/

Total Adjusted Annual Income equals the total of all Sources of Income minus Payments Transferred to Other QPs and/or the Unified Marketing Plan Equalization Fund.

8.2/

Section 1150.151 (a) of the Order states that the administrative expenses incurred by the National Dairy Board shall not exceed 5 percent of the projected revenue of that fiscal
year. In this regard, we urge you to keep the administrative expenses of your organization to a minimum.

8.3/

Total Funds Available for Future Year Programs equals Total Annual Expenditures and UDIA dues subtracted from Total Adjusted Annual Income.

9. HAVE YOU PROVIDED YOUR ANNUAL AUDIT? IF NOT, EXPLAIN WHY.
Yes

No

10. HAVE YOU PROVIDED YOUR ANNUAL REPORT?
Yes

No

11. PROVIDE YOUR AUDITOR’S LETTER OF COMMENTS THAT ADDRESSES THE FIVE CRITERIA (ITEMS A-E) OF THE ACCOMPANYING GUIDANCE
FOR FORM DA-15-CG.
I hereby certify that the information provided above is true, complete, and correct to the best of my knowledge. If producers or importers are
eligible to receive a refund of their contributions, I also certify that the producer’s or importer’s refund requests will be handled in accordance
with the Order. The Secretary of Agriculture may examine our books, records, files, and facilities to verify any of the information submitted and
may procure other information to verify this organization's eligibility for qualification.
I agree to notify AMS, Dairy Programs of any changes in our organizational structure, including merger or other types of consolidation; changes
that may affect our program's continued qualification (see items 2 through 6); or if our program is discontinued.
NAME

TITLE

SIGNATURE

DATE

FORM DA-15-CG (Rev. 04/17) (Reverse)

FORM DA-15-CG (Rev. 04/17)

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the
USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited
from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual
orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political
beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all
bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print,
audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600
(voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may
be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found
online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and
provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992.
Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary
for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
[email protected]. USDA is an equal opportunity provider, employer, and lender.