M-21 Membership Report by Order 30 Qualified Cooperative Asso

Report Forms Under Milk Marketing Order Programs (From Milk Handlers and Milk Marketing Cooperatives)

M-21 Membership Report Order 30 Coop 12-7-16

Report Forms Under Milk Marketing Order Programs (From Milk Handlers and Milk Marketing Cooperatives)

OMB: 0581-0032

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FEDERAL MILK MARKET ADMINISTRATOR

MEMBERSHIP REPORT BY ORDER 30 QUALIFIED COOPERATIVE ASSOCIATION

FORM APPROVED, OMB 0581-0032

UPPER MIDWEST MARKETING AREA
P.O. BOX 4469
LISLE, ILINOIS 60532-9469

(1) NOTICE OF ADDITION TO MEMBERSHIP
M-21

(2) NOTICE OF MEMBER TRANSFERRING BETWEEN PLANTS
Date
(NAME OF HANDLER TO WHOM MEMBER IS DELIVERING)

PATRON
NUMBER

(PLANT)

PATRON'S NAME (FIRST AND LAST)
ADDRESS & LOCATION OF FARM

STOCK
CERTIFICATE
OR
CONTRACT NO.

DATE OF
CONTRACT
OR
CERTIFICATE

EFFECTIVE
DATE OF
CHECK OFF

OLD MEMBER TRANSFERRING
TO ABOVE PLANT FROM
PLANT

PATRON NO.

(PLEASE PRINT)

NAME
ADDRESS
FARM LOC.
TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

TWP.

COUNTY

STATE

NAME
ADDRESS
FARM LOC.
NAME
ADDRESS
FARM LOC.
NAME
ADDRESS
FARM LOC.
NAME
ADDRESS
FARM LOC.
The records of this association are available for your examination for the purpose of verifing the above data.

BY

TITLE
(PERSON AUTHORIZED TO SIGN FOR THE ASSOCIATION)

(NAME OF QUALIFIED COOPERATIVE ASSOCIATION)

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 hour(s) 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 alernative
means of 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.


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Authordwiest
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