Monthly Report of Payments Received by Cooperative Assoc

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

United States Department of Agriculture
Agricultural Marketing Service, Dairy Programs
Market Administrator
Federal Milk Orders 6 & 7—Florida and Southeast Marketing Areas
2763 Meadow Church Road, Suite 100, Duluth, GA 30097
Tel: (770) 682‐2501—Fax: (770) 545-8850
Email: [email protected] Website: www.fmmatlanta.com
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)).

HANDLER

** If applicable

Gross
$ Amount
Due

$ Adjustments
(-) or +

Net
Amount
Due $

FIRST ADVANCE
Date
Received
$ Amount

SECOND ADVANCE**
Date
$ Amount
Received

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:
(Person Authorized to Sign for Handier)

TITLE:

DATE:

FINAL SETTLEMENT
Date
$ Amount
Received

USDA, AMS, Dairy Programs
Market Administrator
2763 Meadow Church Road, Suite 100, Duluth, GA 30097
(770) 682-2501
Monthly Report of Payments Received by Cooperative Association from Handlers

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