DA-228 Request for Applicant Number

Reproduce Locally Include form number and edition date on all reproductions FORM APPROVED –OMB NO 0581-0283

	U.S. Department of Agriculture Agricultural Marketing Service Dairy Programs Request for Applicant Number
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. This valid OMB control number for this collection is 0581-0283. The time required to complete this information collection is estimated to average 3 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 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 How to File a Program Discrimination Complaint 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. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.
1. COMPANY NAME AS REGESTERED WITH THE IRS
2. FEDERAL TAX ID NUMBER
3. DOING BUSINESS AS IF APPLICABLE
4. BILLING ADDRESS LINE 1
5. BILLING ADDRESS LINE 2
6. CITY			7. STATE	8. ZIP CODE
9. CONTACT
10. PHONE NUMBER				EXT
11. FAX NUMBER
12. E-MAIL ADDRESS
13. COMPANY MAILING ADDRESS (IF DIFFERENT THAN BILLING)		14. P.O. BOX AND/OR STREET ADDRESS
		15. CITY, STATE, ZIP
16. CONTACT FOR MAILING ADDRESS (IF DIFFERENT THAN BILLING)
17.E-MAIL FOR CONTACT (IF DIFFERENT THAN BILLING)
MAIL TO:	PLEASE SUBMIT THE COMPLETED FORM TO THE DAIRY GRADING PROGRAM PHONE: 630-437-5073 FAX: 630-437-5060 EMAIL: [email protected] USDA, AMS, DAIRY 650 East Diehl Rd, Suite 100 Naperville, IL 60563

DA-228 (012/21)