Payments Made to a Cooperative Association

Form Approved, OMB 0581-0032

Exp.XX/XXXX

UNITED STATES DEPARTMENT of AGRICULTURE

AGRICULTURAL MARKETING SERVICE - DAIRY PROGRAMS
MARKET ADMINISTRATOR
Federal Orders 6 and 7

Phone:

770-682-2501

Mailing Address

Fax:

770-545-8850

2763 Meadow Church Road, Suite 100

E-Mail:

[email protected]

Duluth, GA 30097

Home Page: www.fmmatlanta.com

PAYMENTS MADE TO A COOPERATIVE ASSOCIATION
Please submit a separate form for payment to each cooperative association.
COOPERATIVE ASSOCIATION:

MONTH:

ADDRESS:

ORDER:

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

Product
Pounds

Butterfat
Pounds

Product
Pounds

Cwt.
Rate

Cwt.
Rate

Value

Date
Mailed

Amount

PRODUCER MILK - UNIFORM

TOTAL PRODUCER MILK
OTHER SOURCE RECEIPTS
GRAND TOTAL

PAYMENTS

Check
Number

First Advance
Second Advance**
Final
** If Applicable

TOTAL PAYMENTS

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.

HANDLER

SIGNED
(Person Authorized to Sign for Handier)

DATE

TITLE

USDA, AMS, Dairy Programs
Market Administrator
2763 Meadow Church Road, Suite 100, Duluth, GA 30097
(770) 682-2501
Payments Made to a Cooperative Association

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