California FMMO Brokerage Rept.

OMB No. 0581- 0032
"This report is required by the Order in accordance with 7 U.S.C. 608c 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 fi ne of up to $5,000 per day
(7 U.S.C. 608c (14)(A))."

XXX FEDERAL MILK ORDER XXX
Handler Name

Address: XXX
Tel: XXX

Report on this form all movements of bulk fluid milk products and
fluid cream products made at your direction, for which you are not
required to submit a plant report or a bulk tank unit report to the
Market Administrator.
This report properly prepared and signed must be submitted to
the above address on or before the of the month following the
month for which the report is prepared.

CALIFORNIA FMMO
BROKERAGE REPORT
REPORT OF PRODUCT MOVEMENTS NOT OTHERWISE REPORTED

Month/Year:
DO NOT WRITE IN SHADED AREAS

SHIPPER
Date
Shipped

Handler Name

Shaded Area For Market Administrator Use Only

RECEIVER
Plant Location or Bulk
Tank Unit Name

Date
Code Received

Handler Name

PRODUCT
Plant Location

Code

Name

Code

Pounds of
Product

Pounds of
Butterfat/Solids Class

SHIPPER
Date
Shipped

Handler Name

RECEIVER
Plant Location or Bulk
Tank Unit Name

For Market Administrator Use Only

Operator 1

Date
Code Received

Handler Name

PRODUCT
Plant Location

Code

Name

Code

Pounds of
Product

Pounds of
Butterfat/Solids Class

The information provided is complete and accurate to the best of my knowledge and belief.

Handler's Name:
Operator 2

Signed by:
(Person authorized to sign on behalf of handler)

Title:

Date:

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 15 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 fi le a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.