Payments Made to a Cooperative Association

Form Approved, OMB 0581-0032

UNITED STATES DEPARTMENT of AGRICULTURE
AGRICULTURAL MARKETING SERVICE - DAIRY PROGRAMS
MARKET ADMINISTRATOR
Federal Orders 6 and 7
Phone:

770-682-2501

Fax:
E-Mail:

770-822-1038
[email protected]

Mailing Address
1550 North Brown Rd., Ste. 120
Lawrenceville, Georgia 30043

Home Page: fmmatlanta.com

PAYMENTS MADE TO A COOPERATIVE ASSOCIATION
Please submit a separate form for payment to each cooperative association.
COOPERATIVE ASSOCIATION:

MONTH:

ADDRESS:

ORDER:

This report is required by the order in accordance with 7 U.S.C. 608 c 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. W& (14) (B)) or, upon conviction, in a fine of up to $5,000 per day (7 U.S.C. 608c (14) (A)).
Market Administrator Use Only

Product
Pounds

Butterfat
Pounds

Product
Pounds

Cwt.
Rate

Cwt.
Rate

Value

Date
Mailed

Amount

PRODUCER MILK - UNIFORM

TOTAL PRODUCER MILK
OTHER SOURCE RECEIPTS
GRAND TOTAL

PAYMENTS

Check
Number

First Advance
Second Advance**
Final
** If Applicable

TOTAL PAYMENTS

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.

HANDLER

SIGNED
(Person Authorized to Sign for Handier)

DATE

TITLE

USDA, AMS, Dairy Programs
Market Administrator
1550 North Brown Rd., Ste. 120, Lawrenceville, GA 30043
(770) 682-2501
Payments Made to a Cooperative Association

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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.
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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, 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.