California FMMO Brokerage Rept.

OMB No. 0581-0032
Exp. XX/XXXX
"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

Date
Shipped

SHIPPER
Handler Name

Shaded Area For Market Administrator Use Only

Plant Location or Bulk
Tank Unit Name

Date
Code Received

RECEIVER
Handler Name

PRODUCT
Plant Location

Code

Name

Code

Pounds of
Product

Pounds of
Butterfat/Solids Class

Date
Shipped

SHIPPER
Handler Name

Plant Location or Bulk
Tank Unit Name

For Market Administrator Use Only

Operator 1

Date
Code Received

RECEIVER
Handler Name

PRODUCT
Plant Location

Code

Name

Code

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:

Pounds of
Product

Pounds of
Butterfat/Solids Class

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.
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. 20250-9410; (2) fax:
(202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.