PH-1 Information Report for Designation as Producer-Handler

1930 – 220th St. SE, Ste. 102
Bothell, WA 98021

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAMS

N

Phone: (425) 487-6009
Fax: (425) 487-2775

FEDERAL MILK ORDERS 124 & 131

E-Mail: [email protected]

N

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

PH – 1
Information Report for Designation as Producer-Handler

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.
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

Form PH-1

DAIRY PROGRAMS

1930 – 220th St. SE, Ste. 102
Bothell, WA 98021
Phone: (425) 487-6009

N

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

FEDERAL MILK ORDERS 124 & 131

N
N

Fax: (425) 487-2775
E-Mail: [email protected]

Scottsdale, AZ 85254
Phone: (602) 547-2909
Fax: (602) 547-2906
E-Mail: [email protected]

INFORMATION REPORT FOR DESIGNATION AS PRODUCER-HANDLER
IMPORTANT: Producer-handler means a person who operates a dairy farm and a distributing plant from which there is
route disposition within the marketing area during the month not to exceed 3 million pounds and who the market
administrator has designated a producer-handler after determining that all of the requirements of §1124.10 and/or
§1131.10 have been met. In addition, cancellation of producer-handler status can occur if a producer-handler markets
milk in any part as Class I milk to a non-pool distributing plant of any other handler. Farms associated with the producerhandler cannot be subject to inclusion and participation in a State-operated milk classification and pricing program that has
market wide pooling.
PRIVACY ACT STATEMENT. Producer-Handlers must meet the requirements of 7 CFR §1124.10 and/or §1131.10, in
order to qualify for the producer-handler exemption. Federal regulations, as set forth in 7 CFR §1000.25, state that the
Market Administrator is responsible for the administration of the marketing order. This authority includes the responsibility
to verify that entities claiming the exemption are in fact eligible for that status. The collection of this information is
authorized by 7 CFR §1000.25(c)(6). The information will be used, along with any accompanying documentation, to make
that determination and to insure compliance with the applicable federal order provisions. Furnishing your proprietary
information is voluntary. However, failure to provide any part of the information may result in a determination that you are
not eligible for the producer-handler exemption. This information is confidential, and subject to the limitations and
sanctions specified in the Privacy Act (5 USC §2105).
SECTION I – OWNERSHIP INFORMATION
1. Name of Handler:
2. Business Form:

Sole Proprietorship
Partnership
Limited Liability Company (LLC)
Corporation

3. Business Documentation: If the entity is a partnership, LLC, or corporation, obtain a current copy of the
partnership agreement, LLC organization documents, or corporate charter.
4. Participant(s): Persons owning shares in the LLC or corporation, or list all partners of the partnership.
Name:
Address:
Phone:

E-mail:

Name:
Address:
Phone:

E-mail:

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4. Participant(s): (Continued)
Name:
Address:
Phone:

E-mail:

Name:
Address:
Phone:

E-mail:

5. Business Address:
6. Contact information:
Phone Number:

Fax:

E-mail:
SECTION II – MILK PRODUCTION RESOURCES AND FACILITIES
List and describe in this section all the milk production resources and facilities, of the type shown1. Which you, your partner(s), or any of your stock holders own, operate, or control either directly,
indirectly, or partially; and
2. Any others in which you have an interest in any way, including contractual arrangement. Show in Part
A below those production resources and facilities which you wish determined to be your milk
production resources and facilities in connection with your designation as a producer-handler. Show
in Part B those that you claim should not be designated a part of your milk production resources and
facilities because they do not constitute an actual or potential source of milk supply for your operation
as a producer-handler. (Note: You must be able to prove each claim to the satisfaction of the Market
Administrator, and any listed items for which such a claim cannot be sustained will be designated a
part of your operation.)
PART A – ITEMS TO BE CONSIDERED A PART OF THE
DESIGNATED PRODUCTION RESOURCES AND FACILITIES
MILK PRODUCTION FACILITIES
Farm 1: Name used for that Property:
Number of Acres:

County

State

Legal Description or reference to Deed:
Lease Information:
Bovine Population:

Total Animals

Milking Cows

Buildings housing the herd: Number of buildings

Cow Capacity
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PART A - MILK PRODUCTION FACILITIES (Continued)
Farm 2: Name used for that Property:
Number of Acres:

County

State

Legal Description or reference to Deed:
Lease Information:
Bovine Population:

Total Animals

Milking Cows

Buildings housing the herd: Number of buildings

Cow Capacity

Farm 3: Name used for that Property:
Number of Acres:

County

State

Legal Description or reference to Deed:
Lease Information:
Bovine Population:

Total Animals

Milking Cows

Buildings housing the herd: Number of buildings

Cow Capacity

Farm 4: Name used for that Property:
Number of Acres:

County

State

Legal Description or reference to Deed:
Lease Information:
Bovine Population:

Total Animals

Milking Cows

Buildings housing the herd: Number of buildings

Cow Capacity

NOTE: If you operate more than 4 farms, identify the remainder on a separate piece of paper.
PART B – ITEMS NOT TO BE CONSIDERED A PART OF THE
DESIGNATED PRODUCTION RESOURCES AND FACILITIES
Farm 1: Name used for that Property:
Number of Acres:

County

State

Legal Description or reference to Deed:
Lease Information:
Bovine Population:

Total Animals

Milking Cows

Buildings housing the herd: Number of buildings

Cow Capacity

Page 4 of 6

PART B – OTHER MILK PRODUCTION FACILITIES (Continued)
Give reasons why you feel each of the items listed above should not be designated as part of your milk
production resources and facilities (Use a separate piece of paper if needed).

NOTE: If you operate more than 1 farm not to be considered a part of the designated production resources
and facilities, identify the remainder on a separate piece of paper.
SECTION III – MILK HANDLING, PROCESSING, AND DISTRIBUTION RESOURCES AND FACILITIES
List and describe in this section all resources and facilities of the types shown (including store outlets) used for
handling, processing, and distributing milk or milk products within the marketing area –
1. Which you own, operate, or control, either directly, indirectly, or partially, or
2. In which you in any way have an interest, including any contractual arrangement; and management or
control.
3. Any others with respect to which you directly or indirectly exercise any degree of management or
control.
Provide the requested information for each item listed. Show in the right hand column for any item of real
property whether you own, lease, rent, or otherwise control each. If your control is not through ownership,
lease, rental, describe on a separate piece of paper how your control is executed.
PROCESSING PLANT(S) INFORMATION
Processing Plant Location

Legal Description or

Owned, Leased, Rented,

(Street Address, City, State, Zip)

Reference to Deed

Or Other

STORE INFORMATION
Owned,
Legal Description

Number

Principal

Leased,

Store Location

or

of

Distribution

Rented, Or

(Street Address, City, State, Zip)

Reference to Deed

Routes

Area

Other

Page 5 of 6

DISTRIBUTOR INFORMATION
Legal Description

Principal

Distributor Location

or

Distribution Area

(Street Address, City, State, Zip)

Reference to Deed

Owned, Leased,
Rented, Or Other

Sales to Alaska or Outside the United States?

SECTON IV: AFFILIATED PERSONS
List below the names of all other persons who have or exercise any degree of direct, indirect, or partial
ownership, operation, or control of your operation either as a dairy farmer or a handler. Also list any person
(showing trade name if any) with whom you have any contractual arrangement with respect to your operation
either as a dairy farmer or a handler. Provide the information requested for each person.
Specify Item of
Name

Address

Relationship

Concern

Identify parties who are empowered to sign reports on behalf of the business:
Name

Area of Authority

Signature

Owner (Y/N)

I declare under penalties provided by law, that the information contained in this report (including any
accompanying schedules and statements) has been examined by me and to the best of my knowledge and
belief is true, correct, and complete. I also certify that I am authorized to sign this information report.
Prepared by:

On (Date)

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