Designation of Persons Authorized to Sign Handler Report

Form Approved, OMB 0581-0032
Exp. XX/XXXX

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE DAIRY
- PROGRAMS
MARKET ADMINISTRATOR
Federal Orders 6 and 7
2763 Meadow Church Road, Suite 100,
Duluth, GA 30097

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:
SIGNED:

DATE:

(Signature of Authorizing Agent)

TITLE:

USDA, AMS, Dairy Programs
Market Administrator
2763 Meadow Church Road, Suite 100, Duluth, GA 30097
(770) 682-2501
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 30 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.
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
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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
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