HR-EZ Reimbursement Claim Form

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Overview

Cover Sheet
HR-EZ
HR-EZ_TOTAL Sched 1
HR-EZ_OUT Sched 2
HR-EZ_INV Sched 3

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Sheet 1: Cover Sheet

UNITED STATES DEPARTMENT OF AGRICULTURE

Address: XXX

AGRICULTURAL MARKETING SERVICE

XXX

DAIRY PROGRAMS

Phone: XXX

Fax: XXX

XXX FEDERAL MILK ORDER XXX

E-mail: XXX

HR - EZ

Report of Receipts and Utilization

(includes schedules 1, 2, and 3)

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 1 hour 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. 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. (Not all prohibited bases apply to all programs.) Persons with 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.

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Sheet 2: HR-EZ

UNITED STATES DEPARTMENT OF AGRICULTURE

Form HR-EZ, Page 1

AGRICULTURAL MARKETING SERVICE

Form Approved, OMB No. 0581-0032

Address: XXX

DAIRY PROGRAM

XXX

Phone: XXX

Fax: XXX

XXX FEDERAL MILK ORDER XXX

E-mail: XXX

REPORT OF RECEIPTS AND UTILIZATION

Handler Name

For M. A. Use Only

Plant Location

Month-Year

Order

Month/Year

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. 608c (14)(B)) or, upon conviction, in a fine of up to $5,000 per day (7 U.S.C. 608c (14) (A)).

Line

Product

Butterfat

BEGINNING INVENTORIES

Pounds

Pounds

1

Class I (Packaged)

2

Class IV (Bulk)

RECEIPTS

For M.A. Use Only

Product

Butterfat

Pounds

Pounds

3

Own Farm Production

(No. of Farms)

4

Other Dairy Farms

(No. of Farms)

OTHER RECEIPTS

Type

Form

Product

Class

For M.A. Use Only

Product

Butterfat

Identify Name, City, State

1/

2/

3/

Type

Form

Prod.

Class

Pounds

Pounds

5

6

7

8

9

10

11

Nonfluid milk products: Class II (from Sch. 1, Line 15)

Lbs.

x 10.54

12

Nonfluid milk products: Class I, III, & Loss (from Sch. 1, Line 16)

Lbs.

x 10.54

13

TOTAL RECEIPTS AND BEGINNING INVENTORIES

UTILIZATIONS

Type

Form

Product

Class

For M.A. Use Only

14

Total Class I Route Disposition (In & Out of Marketing Area)

15

Closing Inventory -- Class I Packaged

16

Closing Inventory -- Bulk (Class IV)

17

Movements to Other Plants (Identify)

18

19

20

21

22

23

Used to Produce (Identify Product)

24

25

26

27

28

29

30

31

32

NFMS Used to Fortify FMP

Lbs.

x 9.89

33

TOTAL UTILIZATIONS AND ENDING INVENTORIES

34

SHRINKAGE (OVERAGE)

1/ (T)ransfer; (D)iversion. 2/ (B)ulk weights; (F)arm weights; (P)ackaged. 3/ (W)hole; (S)kim; (Cr)eam; (Co)ndensed; (V) Various Packaged.

Date

Person Authorized to Sign for Handler

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Sheet 3: HR-EZ_TOTAL Sched 1

	Handler:			Location:			Month & Year:				Form HR-EZ, Schedule 1
XXX FEDERAL MILK ORDER XXX
TOTAL ROUTE DISPOSITION
Line		PRODUCT	AVG.	BUTTERFAT		HALF				HALF	OTHER
	PRODUCT (Specify) 1/	POUNDS	TEST	POUNDS	GALLONS	GALLONS	QUARTS	PINTS	10 OZ	PINTS	Specify: ____
1	Homo - Whole
2
3	Flavored Milk
4
5	2% Reduced Fat
6
7	1% Lowfat - Plain
8
9	Skim Nonfat - Plain
10
11	Flavored Drink
12
13	Buttermilk
14
15	TOTAL ROUTES				Total to Page 1, Line 14
	1/ Identify products of different butterfat tests on separate lines.
	RECONCILIATION OF NONFLUID MILK PRODUCTS
		Other (Specify):		Butter		Nonfat Dry Milk
		Pounds		Pounds	Butterfat	Pounds		Butterfat
	AVAILABILITY:							x .008
1	Beginning Inventory
2	Purchases
3	Manufacture
4	Sales (minus)
5	Dumpage (minus)
6	Ending Inventory (minus)
7	Pounds Available for Use
8	ACCOUNTABILITY: (USE)
9	Used to Fortify Class I
10	Used in Class II
11	Used in Class III
12	Total Pounds Used
13	Loss (Line 7 Minus 12)
14	TOTAL NONFLUID RECEIPTS:
15	Nonfluid: Class II
16	Nonfluid: Class I & III, (plus Loss)

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Sheet 4: HR-EZ_OUT Sched 2

	Handler:			Location:			Month & Year:				Form HR-EZ, Schedule 2
XXX FEDERAL MILK ORDER XXX
OUT-OF-AREA ROUTE DISPOSITION				IDENTIFY AREA 2/:
Line		PRODUCT	AVG.	BUTTERFAT		HALF				HALF	OTHER
	PRODUCT (Specify) 1/	POUNDS	TEST	POUNDS	GALLONS	GALLONS	QUARTS	PINTS	10 OZ	PINTS	Specify: ____
1	Homo - Whole
2
3	Flavored Milk
4
5	2% Reduced Fat - Plain
6
7	1% Lowfat - Plain
8
9	Skim Nonfat - Plain
10
11	Flavored Drink
12
13	Buttermilk
14
15	TOTAL
OUT-OF-AREA ROUTE DISPOSITION				IDENTIFY AREA 2/:
Line		PRODUCT	AVG.	BUTTERFAT		HALF				HALF	OTHER
	PRODUCT (Specify) 1/	POUNDS	TEST	POUNDS	GALLONS	GALLONS	QUARTS	PINTS	10 OZ	PINTS	Specify: ____
16	Homo - Whole
17
18	Flavored Milk
19
20	2% Reduced Fat - Plain
21
22	1% Lowfat - Plain
23
24	Skim Nonfat - Plain
25
26	Flavored Drink
27
28	Buttermilk
29
30	TOTAL
	1/ Identify products of different butterfat tests on separate lines.
	2/ Identify Federal order number, city & state.

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Sheet 5: HR-EZ_INV Sched 3

	Handler:			Location:			Month&Year				Form HR-EZ, Schedule 3
XXX FEDERAL MILK ORDER XXX
CLOSING INVENTORIES
CLASS I
Line		PRODUCT	AVG.	BUTTERFAT		HALF				HALF	OTHER
	PRODUCT (Specify) 1/	POUNDS	TEST	POUNDS	GALLONS	GALLONS	QUARTS	PINTS	10 OZ	PINTS	Specify: ___
1	Homo - Whole
2
3	Flavored Milk
4
5	2% Reduced Fat - Plain
6
7	1% Lowfat - Plain
8
9	Skim Nonfat - Plain
10
11	Flavored Drink
12
13	Buttermilk
14
15	TOTAL	-		-	Total to Page 1, Line 15
	1/ Identify products of different butterfat tests on separate lines.
CLASS IV
16	Raw Milk
17	Skim
18	Buttermilk
19	Bulk Cream
20	Concentrated FMP
21	TOTAL, BULK	-		-	Total to Page 1, Line 16