Form HR-76(a) Partially Regulated Dist. Plant Report of Route Disposit

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAMS

1930-220th St. SE, Ste. 102
Bothell, WA 98021
Phone: (425) 487-6009
Fax: (425) 487-2775
E-mail: [email protected]

FEDERAL MILK ORDERS 124 & 131

4835 E Cactus Rd., Ste. 440
Scottsdale, AZ 85254
Phone: (602) 547-2909
Fax: (602) 547-2906
E-mail: [email protected]

HR - 76(a)
Report of Route Disposition Into Federal Milk Marketing Orders

Note: This cover page is for information purposes only and does not need to be submitted to the market administrator's office.

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 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. 202509410; (2) fax: (202) 690-7442; or (3) email: [email protected].
USDA is an equal opportunity provider, employer, and lender.

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAMS

Form HR-76(a)
1930-220th St. SE, Ste. 102

OMB 0581-0032
Exp. XX/XXXX
4835 E Cactus Rd., Ste. 440

Bothell, WA 98021

Scottsdale, AZ 85254

Phone: (425) 487-6009

Phone: (602) 547-2909

FEDERAL MILK ORDERS 124 & 131

Fax: (425) 487-2775

Fax: (602) 547-2906

E-mail: [email protected]

E-mail: [email protected]

This report is required by the order in accordance with 7 U.S.C. 608c 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)).

Partially Regulated Distributing Plant
Report of Route Dispositions Into Federal Milk Marketing Orders

Handler

Delivery Period

Federal Order:
Federal Order:
Federal Order:
Product Pounds Fat Pounds Product Pounds Fat Pounds Product Pounds

Product
Homo - Whole
Homo - Whole - Organic
Flavored Milk
Flavored Milk - Organic
2% Reduced Fat - Plain
2% Reduced Fat - Fortified
2% Reduced Fat - Organic
1% LowFat - Plain
1% LowFat - Fortified
1% LowFat - Organic
Skim Nonfat - Plain
Skim Nonfat - Fortified
Skim Nonfat - Organic
Flavored Drink
Flavored Drink - Organic

Buttermilk - Plain
Buttermilk - Whole
Buttermilk - Organic
Eggnog

Total

Signature

Date

Fat Pounds