DA-15-CG Application for Initial or Continued Qualification

Approved - OMB No. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE

DAIRY PROGRAM

APPLICATION FOR INITIAL OR CONTINUED QUALIFICATION OF DAIRY PRODUCT PROMOTION, RESEARCH,

OR NUTRITION EDUCATION PROGRAM

(Under Dairy Production Stabilization Act of 1983)

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 0581-0093. The time required to complete this information collection is estimated to average 3 hours 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.

USDA, AMS, DAIRY PROGRAM

PROMOTION, RESEARCH, AND PLANNING DIVISION STOP XXXX, ROOM XXXX-S

STREET

CITY, STATE, ZIP

Information is collected in order to determine initial or continued qualification of dairy product promotion, research or nutrition education programs (7 CFR 1150.153). Application is voluntary but qualification is necessary to receive a benefit. Information from organizations is held confidential in the manner set forth in 7 CFR 1150.173, except for any release required under the Freedom of Information Act.

The Dairy Promotion and Research Order (7 CFR 1150.101 et seq.) provides in §1150.153 that any organization that conducts a dairy product promotion, research, or nutrition education program may request qualification of its program from the Secretary of Agriculture. Producers or importers contributing to a qualified program (QP) may receive credit for contributions to such program pursuant to §1150.152 of the Order.

To be eligible for initial or continued qualification, the program must:

1. Be engaged in dairy product promotion, research, or nutrition education activities that are intended to increase consumption of milk and dairy products generally.

2. Except for programs operated under the laws of the United States or any State, and except for importer programs, have been active and ongoing before November 29, 1983.

3. Be financed primarily by producers, either individually or through cooperative associations, or for importer programs, be financed primarily by importers.

4. Not use a brand or trade name in its advertising and promotion of dairy products unless approved by the National Dairy Promotion and Research Board and the Secretary.

5. Certify to the Secretary that any requests from producers or importers for refunds under its programs will be honored by forwarding to the Board or to the qualified program designated by the producer or importer that portion of the refund equal to the amount of the credit given to the producer or importer because of his/her participation in the program. The amount of such credit may not exceed 10 cents per hundredweight for a producer and 2.5 cents per hundredweight or equivalent thereof, for an importer.

6. Not use program funds for the purpose of influencing governmental policy or action.

The following information is to be submitted by each organization requesting initial or continued qualification of its dairy product promotion, research, or nutrition education program(s). If additional space is required, provide an additional attachment identified by item number.

1. CURRENT NAME AND ADDRESS OF ORGANIZATION (COMPLETE MAILING ADDRESS):

Name: Telephone No.: Address: Fax Number: Address: Email Address: City: State: Zip:

2. DOES YOUR ORGANIZATION CONDUCT OR FUND A DAIRY PRODUCT: (CHECKALL THAT APPLY)

   1. Promotion Program? B. Research Program? C. Nutrition Education Program?

3. IS YOUR ORGANIZATION PRIMARILY FINANCED (50% ORMORE) DIRECTLYBYPRODUCERS, COOPERATIVEASSOCIATIONS AND/OR				4. ARE CONTRIBUTIONS BY PRODUCERS OR IMPORTERS REFUNDABLE TO SUCHPRODUCERS OR IMPORTERS?
IMPORTERS? Yes		No		Yes		No

5. DOESYOUR PROGRAM UTILIZE A BRAND OR TRADENAME IN ITS ADVERTIZING ANDPROMOTION OFDAIRY PRODUCTS?

5. DOES YOUR ORGANIZATION USE PROGRAM FUNDSFOR THE PURPOSE OF INFLUENCINGGOVERNMENTALPOLICYOR ACTION?□

5. IF YOUR PROGRAM OPERATES UNDER STATE LAW, WHAT IS THE MANDATORY ASSESSMENT RATE PER HUNDREDWEIGHT UNDER THAT PROGRAM? PLEASE LIST THE AMOUNT OF THE STATE ASSESSMENT OR N/A (NOT APPLICABLE).

CENTS PER HUNDREDWEIGHT

DA-15-CG (Expiration Date xx/xx/20xx) Page 1 of 3 See reverse for burden/non-discrimination statement

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:

DA-15-CG (Expiration Date xx/xx/20xx) Page 2 of 3

(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW., Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

5. PROVIDE THE FOLLOWING INFORMATION ON ANNUAL INCOME AND EXPENDITURES FOR THE CALENDAR YEAR ENDING:

(REFERENCE THE ACCOMPANYING ADDITIONAL INSTRUCTIONS FOR FORM DA-15-CG.) (YEAR)

SOURCES OF TOTAL ANNUAL INCOME:

CARRYOVER FROM PREVIOUS YEAR (This should be the same as last year's reported "Total Funds Available for

Future Year Programs.") ................................................................................................................................. $

CURRENT YEAR INCOME (Provide total income for each line item. Separately, attach a schedule of income and/or your accounting system for all sources of current year income. List each separate source and amount of income. DO NOT list individual producers or importers. List funds received from and transferred to each QP and for the Unified Marketing Plan Equalization Fund separately.)

PRODUCER REMITTANCES ........................................................................................................................................

ADD: PAYMENTS RECEIVED FROM OTHER QPS ....................................................................................................... + ADD: PAYMENTS RECEIVED FROM UNIFIED MARKETING PLAN EQUALIZATION FUND .............................................. + SUBTRACT: PAYMENTS TRANSFERRED TO OTHER QPS ............................................................................................ (-) SUBTRACT: PAYMENTS TRANSFERRED TO UNIFIED MARKETING PLAN EQUALIZATION FUND ................................... (-)

OTHER INCOME SOURCES.........................................................................................................................................

TOTAL ADJUSTED ANNUAL INCOME ^8.1/ .................................................................................................... $

EXPENDITURES:

(Provide total expenditures spent directly by your organization for each line item. Separately, attach a schedule of expenses and/or your accounting system reports for each expenditure category, including a project description(s) and related costs. If no funds were spent in a line item, indicate zero.)

ADVERTISING, PROMOTION, AND SALES (AP&S) EXPENDITURES FOR:

FLUID MILK AP&S .......................................................................................

CHEESE AP&S ..............................................................................................

BUTTER AP&S .............................................................................................. FROZEN DAIRY PRODUCTS AP&S ................................................................. OTHER AND MULTI-PRODUCT AP&S EXPENDITURES.....................................

SUBTOTAL FOR AP&S.............................................................................................. =

NUTRITION EDUCATION EXPENDITURES ...................................................................................................................

NUTRITION RESEARCH .............................................................................................................................................

DAIRY PRODUCT RESEARCH ....................................................................................................................................

MARKET AND ECONOMIC RESEARCH .......................................................................................................................

PUBLIC AND INDUSTRY COMMUNICATIONS ..............................................................................................................

UNIFIED MARKETING PLAN .....................................................................................................................................

ADMINISTRATIVE ^8.2/ ................................................................................................................................................

OTHER EXPENDITURES .............................................................................................................................................

TOTAL ANNUAL EXPENDITURES ................................................................................................................

UDIA MEMBERSHIP DUES (Only) ...........................................................................................................................

TOTAL ANNUAL EXPENDITURES AND UDIA DUES ..............................................................................

TOTAL FUNDS AVAILABLE FOR FUTURE YEAR PROGRAMS ^8.3/ ....................................................... $

1. / Total Adjusted Annual Income equals the total of all Sources of Income minus Payments Transferred to Other QPs and/or the Unified Marketing Plan Equalization Fund.

2. / Section 1150.151 (a) of the Order states that the administrative expenses incurred by the National Dairy Board shall not exceed 5 percent of the projected revenue of that fiscal year. In this regard, we urge you to keep the administrative expenses of your organization to a minimum.

3. / Total Funds Available for Future Year Programs equals Total Annual Expenditures and UDIA dues subtracted from Total Adjusted Annual Income.

9. HAVE YOU PROVIDED YOUR ANNUAL AUDIT? IF NOT, EXPLAIN WHY.					10. HAVE YOU PROVIDED YOUR ANNUAL REPORT?
Yes		No			Yes		No

11. PROVIDE YOUR AUDITOR’S LETTER OF COMMENTS THAT ADDRESSES THE FIVE CRITERIA (ITEMS A-E) OF THE ACCOMPANYING GUIDANCE FOR FORM DA-15-CG.

I hereby certify that the information provided above is true, complete, and correct to the best of my knowledge. If producers or importers are eligible to receive a refund of their contributions, I also certify that the producer’s or importer’s refund requests will be handled in accordance with the Order. The Secretary of Agriculture may examine our books, records, files, and facilities to verify any of the information submitted and may procure other information to verify this organization's eligibility for qualification.

I agree to notify AMS, Dairy Programs of any changes in our organizational structure, including merger or other types of consolidation; changes that may affect our program's continued qualification (see items 2 through 6); or if our program is discontinued.

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