DA-230 Dairy Product Sales Survey

OMB No. 0581-0274

DAIRY PRODUCT SALES SURVEY
Annual Validation Worksheet
U.S Department of Agriculture,
Rm. 2968, South Building
1400 Independence Ave., S.W.
Washington, DC 20250-0225
Phone: 202-720-4392
Fax: 202-690-3410
Email: DPP@ams.usda.gov

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 0581-0274. The time required to complete this information collection
is estimated to average 20 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 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.

USDA AMS collects weekly information on the
sales of dairy products such as cheddar cheese to
be published in the Dairy Products Sales Release.
The information you provide is important to
establish U.S. dairy product prices used in setting
minimum class prices under the Federal Milk
Order program. An accurate response to this
survey is mandatory and subject to verification by
the AMS under Public Law No. 106-532. This law
specifically protects the confidentiality of your
report from public disclosure except as directed
by the US Secretary of Agriculture or the US
Attorney General for enforcement purposes to
ensure compliance with the Dairy Product
Mandatory Reporting program.

Office Use
CC40

CC500

NFDM

Butter

Dry Whey Multi-Plant

Grade

Size

Intra

Organic

Faith

Current Reporter
Potential DPP Reporter
Other Specifications
This worksheet should be completed by an AMS representative with the individual who completes the weekly reports.

Yes

No

1. Does this operation work with other locations producing or marketing Dairy Products?
[Interviewer Note: If yes, complete the Supplement. If no, continue.]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Does this firm sell one million pounds of:
a. Cheddar cheese in 40 pound blocks, colored between 6 and 8 on the National Cheese Institute
color chart, meeting Wisconsin State Brand, USDA Grade A, or better standards?
[Interviewer Note: If yes, complete Section 1a and 1b]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Cheddar cheese in 500 pound barrels, white, meeting Wisconsin State Brand,
USDA Extra Grade, or better standards? [Interviewer Note: If yes, complete Section 1a and 1c]. . . . . . . . . . . . . .
c. Salted butter (80% butterfat), fresh or storage, in 25 kilogram and 68 pound boxes meeting
USDA Grade AA standards? [Interviewer Note: If yes, complete Section 2]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Non-fortified, nonfat dry milk in 25 kilogram bags, 50 pound bags, totes, and tankers meeting
USDA Extra Grade or USPH Grade A standards?
[Interviewer Note: If yes, complete Section 3]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. Edible non-hygroscopic dry whey in 25 kilogram bags, 50 pound bags, totes, and tankers
meeting USDA Extra Grade standards? [Interviewer Note: If yes, complete Section 4]. . . . . . . . . . . . . . . . . . . . . . . .
3. If all of the above are checked “No”, please explain:

Interviewer Note: If all parts of Question 2 are “no”, skip to Back Page. If any are checked “yes” complete all applicable commodity sections.
DA-230

Page 1 of 8

OFFICE USE BOX

Section 1a – All Cheddar Cheese Sales
1. When reporting weekly Cheddar Cheese sales data to AMS,
did you or can you:
[Interviewer Note: Insert correct column heading {Based on OFFICE USE
BOX }, also if Column 1 is “No” ask Column 2 ]

Cur. Reporter New Reporter

Did you

N/A

Yes

No

Can you

Yes

No

a. report price as f.o.b. plant if the product is “shipped out” from
a plant?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. report price as f.o.b. storage facility if the product is “shipped out”
from a storage facility?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. report only complete transactions, i.e. cheddar cheese is “shipped out”
and title transfer occurs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. report only sales of cheddar cheese 4 to 30 days in age?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. report prices without deduction for brokerage fees paid by the
manufacturer?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f. report prices without deduction for clearing charges paid by the
manufacturer?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
g. include CCC purchases?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
h. include sales of products labeled or contracted as sourced from
cows not treated with recombinant bovine somatotropin (rBST)?. . . . . . . . . . . . . . . . . . . . . . . . . . .
i. exclude forward pricing sales: sales in which the selling price is
established (and not adjusted) 30 or more days before the transaction
is completed?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
j. exclude intra-company sales of cheddar cheese?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
k. exclude re-sales of purchased cheddar cheese?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
l. exclude cheddar cheese certified as organic by a USDA-accredited
certifying agent?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .
m. exclude sales of cheddar cheese produced under faith-based close
supervision and marketed at a higher price than the manufacturer’s
wholesale market price for the basic commodity (for example, kosher
cheddar cheese produced with a rabbi on site who is actively involved
in the supervision of the production process)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n. exclude sales under the Dairy Export Incentive Program (DEIP) or
other premium assisted sales (for example: export assistance sales
through the Cooperatives Working Together (CWT) program)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. If any of the above are checked “No”, please explain:

DA-230

Page 2 of 8

OFFICE USE BOX

Section 1b – Cheddar Cheese 40 Pound Block Sales
1. When reporting weekly sales data for Cheddar Cheese in 40 Pound
blocks to AMS, did you or can you:
[Interviewer Note: Insert correct column heading {Based on OFFICE USE
BOX }, also if Column 1 is “No” ask Column 2 ]
a. report only cheese colored between 6 and 8 on the National Cheese
institute color chart? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cur. Reporter New Reporter

Did you

N/A

Yes

No

Can you

Yes

No

b. report only cheese meeting Wisconsin State Brand, USDA Grade A,
or better standards?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. report price reflecting packaging costs for cheese wrapped in
a sealed, airtight package in corrugated or solid fiberboard container
with a reinforcing inner liner or sleeve (excluding all other packaging
cost from the reported price)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. exclude all cheese that will be aged?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.

If any of the above are checked “No”, please explain:

OFFICE USE BOX
Cur. Reporter New Reporter

Section 1c – Cheddar Cheese 500 Pound Barrel Sales
1. When reporting weekly sales data for Cheddar Cheese in 500 Pound
barrels to AMS, did you or can you:
[Interviewer Note: Insert correct column heading {Based on OFFICE USE
BOX }, also if Column 1 is “No” ask Column 2 ]

Did you

N/A

Yes

No

Can you

Yes

No

a. report only white cheese? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. report only cheese meeting Wisconsin State Brand, USDA Extra Grade,
or better standards?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. report the moisture content of the cheddar cheese?.. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. exclude all packaging costs from reported price? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. exclude all cheese with a moisture content greater than 37.7%? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. If any of the above are checked “No”, please explain:

DA-230

Page 3 of 8

OFFICE USE BOX

Section 2 – Butter Sales
1. When reporting weekly Butter sales data to AMS,
did you or can you:
[Interviewer Note: Insert correct column heading {Based on OFFICE USE
BOX }, also if Column 1 is “No” ask Column 2 ]
report only salted butter with butterfat of 80% in 25 kilogram bags
and 68 pound boxes?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. report all fresh or storage butter sales meeting the other reporting
specifications?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a.

Cur. Reporter New Reporter

Did you

N/A

Yes

No

Can you

Yes

No

c. report only butter meeting USDA Grade AA standards? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. report price as f.o.b. plant if the product is “shipped out” from
a plant?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. report price as f.o.b. storage facility if the product is “shipped out”
from the storage facility?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f. report only complete transactions, i.e. butter is “shipped out”
and title transfer occurs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
g. report prices without deduction for brokerage fees paid by
the manufacturer?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
h. report prices without deduction for clearing charges paid by
the manufacturer?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i. include CCC purchases?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
j. include sales of products labeled or contracted as sourced from
cows not treated with recombinant bovine somatotropin (rBST)?. . . . . . . . . . . . . . . . . . . . . .
k. exclude forward pricing sales: sales in which the selling price is established
(and not adjusted) 30 or more days before the transaction is completed?. . . . . . . . . . . . . . . .
l. exclude intra-company sales of butter?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
m. exclude re-sales of purchased butter?. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n. exclude butter certified as organic by a USDA-accredited
certifying agent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o. exclude sales of butter produced under faith-based close supervision and marketed at a
higher price than the manufacturer’s wholesale market price for the basic commodity
(for example, kosher butter produced with a rabbi on site who is actively involved in the
supervision of the production process)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
p. exclude sales under the Dairy Export Incentive Program (DEIP)
or other premium assisted sales (for example: export assistance sales
through the Cooperatives Working Together (CWT) program)?. . . . . . . . . . . . . . . . . . . . . . . . . . .
q. exclude all sales of unsalted butter?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
r. exclude all sales of Grade A butter?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.

If any of the above are checked “No”, please explain:

DA-230

Page 4 of 8

OFFICE USE BOX

Section 3 – Nonfat Dry Milk Sales
1. When reporting weekly Nonfat Dry Milk sales data to AMS,
did you or can you:
[Interviewer Note: Insert correct column heading {Based on OFFICE USE
BOX }, also if Column 1 is “No” ask Column 2 ]

Cur. Reporter New Reporter

Did you

N/A

Yes

No

Can you

Yes

No

a. report only non-fortified, nonfat dry milk in 25 kilogram bags,
50 pound bags, totes, and tankers?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. report only nonfat dry milk meeting USDA Extra Grade or USPH Grade A standards?. . . . . . . . .
c. report price as f.o.b. plant if the product is “shipped out” from a plant?. . . . . . . . . . . . . . . . . . . . . . . .
d. report price as f.o.b. storage facility if the product is “shipped out” from the storage facility? . .
e. report only complete transactions, i.e. nonfat dry milk is “shipped
out” and title transfer occurs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f. report only nonfat dry milk manufactured using low or medium heat process? . . . . . . . . . . . . . . .
g. report prices without deduction for brokerage fees paid by the manufacturer?. . . . . . . . . . . . . . .
h. report prices without deduction for clearing charges paid by the manufacturer?. . . . . . . . . . . . .
i. include CCC purchases?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
j. include sales of products labeled or contracted as sourced from
cows not treated with recombinant bovine somatotropin (rBST)?. . . . . . . . . . . . . . . . . . . . . . . . . . . .
k. exclude forward pricing sales: sales in which the selling price is established
(and not adjusted) 30 or more days before the transaction is completed?. . . . . . . . . . . . . . . . . . . . .
l.

exclude intra-company sales of nonfat dry milk?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

m. exclude re-sales of purchased nonfat dry milk?. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n. exclude nonfat dry milk certified as organic by a USDA-accredited certifying agent? . . . . . . . .
o. exclude sales of nonfat dry milk produced under faith-based close supervision and marketed
at a higher price than the manufacturer’s wholesale market price for the basic commodity
(for example, kosher nonfat dry milk produced with a rabbi on site who is actively involved in
the supervision of the production process)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
p. exclude all sales of nonfat dry milk using high heat process?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q. exclude sales under the Dairy Export Incentive Program (DEIP)
or other premium assisted sales (for example: export assistance sales
through the Cooperatives Working Together (CWT) program)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
r. exclude all sales of nonfat dry milk more than 180 days old?. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
s. exclude all sales of instant nonfat dry milk? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
t. exclude all sales of dry buttermilk products? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.

If any of the above are checked “No”, please explain:

DA-230

Page 5 of 8

OFFICE USE BOX

Section 4 – Dry Whey Sales
1. When reporting weekly Dry Whey sales data to AMS,
did you or can you:
[Interviewer Note: Insert correct column heading {Based on OFFICE USE
BOX }, also if Column 1 is “No” ask Column 2 ]

Cur. Reporter New Reporter

Did you

N/A

Yes

No

Can you

Yes

No

a. report only edible non-hygroscopic dry whey in 25 kilogram
bags, 50 pound bags, totes, and tankers?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. report only dry whey meeting USDA Extra Grade standards?. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. report price as f.o.b. plant if the product is “shipped out” from a plant? . . . . . . . . . . . . . . . . . . .
d. report price as f.o.b. storage facility if the product is “shipped
out” from the storage facility?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. report only complete transactions, i.e. dry whey is “shipped out”
and title transfer occurs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f. report prices without deduction for brokerage fees paid by the manufacturer?. . . . . . . . . . . .
g. report prices without deduction for clearing charges paid by the manufacturer?. . . . . . . . . . .
h. include sales of products labeled or contracted as sourced from
cows not treated with recombinant bovine somatotropin (rBST)?. . . . . . . . . . . . . . . . . . . . . . . .
i. exclude forward pricing sales: sales in which the selling price is established
(and not adjusted) 30 or more days before the transaction is completed?. . . .. . . . . . . . . . . . . . . .
j. exclude intra-company sales of dry whey?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
k. exclude re-sales of purchased dry whey?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
l.

exclude dry whey certified as organic by a USDA-accredited certifying agent? . . . . . . . . . . . . .

m. exclude sales of dry whey produced under faith-based close supervision and marketed at a
higher price than the manufacturer’s wholesale market price for the basic commodity
(for example, kosher dry whey produced with a rabbi on site who is actively involved in the
supervision of the production process)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n. exclude premium assisted sales (for example: seller receives additional monetary
value above sale price from a third party (i.e. government or private entity) for the
export of dairy products based on criteria defined by the third party)?. . . . . . . . . . . . . . . . . . . . . . .
o. exclude all sales of dry whey more than 180 days old?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
p. exclude all Grade A dry whey?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. If any of the above are checked “No”, please explain:

DA-230

Page 6 of 8

Section 5 – Other Information

Yes

No

1. Does another firm report any Dairy Products Price data for this operation?
If yes, who and what products? [Interviewer Note: If no, skip to Question 2]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

a. If yes, does this plant have production sales not included in data submitted through your reporting firm
(i.e. cheese is reported through another firm but your plant also makes and sells dry whey OR your
plant has additional cheese walk-in or spot cash sales outside the information reported by the firm listed)? . .
b. If yes, what products? [Interviewer Note: If no, skip to Question 2]

2. Does this operation make day-to-day marketing decisions for more than one plant?
If yes, please identify all plants, in the Multiple Plant List (page 8), to be included with this firm’s information
before continuing to Question 3. If no, (and the supplement was completed), please determine the location
and contact information to complete the required Annual Validation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Interviewer Note: If plant qualifies, inform respondents the weekly responsibilities and collect contact information.

3. Who is the primary contact at your operation for completing the Dairy Products Prices surveys?
Name:______________________________________

Position:______________________________________________

Telephone: (

Email:________________________________________________

) ____________________________

4. Who is the secondary contact at your operation for completing the Dairy Products Prices survey?
Name:______________________________________

Position:______________________________________________

Telephone: (

Email:________________________________________________

DA-230

) ____________________________

Page 7 of 8

Multiple Plants List Table: [Interviewer Note: List Plant Name, Location, and Dairy Products reported for all
company locations.]
Office Use
Plant
ID

Reporting
ID

Plant Name

Products Report
Reported Type

Location

5. Do you understand the instructions and requirements of the Dairy Product Prices Mandatory
program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

6. Do you need any additional explanation of any definition, question, or issues discussed in the Annual
Validation Worksheet?
If yes, review all sections the respondent would like additional clarification.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General Survey Comments:

OFFICE USE
Cheddar Cheese 40

Cheddar Cheese 500

Butter

NFDM

Dry Whey

Weekly Reporter
Interviewer Name

Respondent Name: __________________________________ Phone: (

) ________________________

Signature: __________________________________________ Date: ________________________

DA-230

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