Approved OMB No. 0581-0093

ID Number

Name 

Address

REPORT OF AMOUNT DUE ON FLUID MILK PRODUCTS MARKETED DURING Month Year

Failure to report or remit amount due may result in a fine of not more than the maximum amount specified in Sec. 3.91 (b)(1)(xxxv) of this title for each violation.

1. Fluid milk products processed and marketed commercially in consumer-type packages. lbs.

2. Add fluid milk products processed and packaged and transferred to other plants. lbs.

3. Subtract fluid milk products processed and packaged and transferred in from other plants. lbs.

4. Subtract fluid milk products exported to locations outside the contiguous 48 States and the District

of Columbia lbs.

5. Deduct Organic Milk Exemption (Per § 1160.215 (b))

If you enter an amount, complete Part A on the reverse side of this report. - lbs.

6. Total fluid milk products processed and marketed commercially in consumer-type packages subject

to the assessment (sum of line 1 through line 5). - lbs.

7. Amount due for this month (line 6 x $.0020). (The rate of $.0020 per pound is equal to 20 cents

perhundredweight). $ -

8. Add or subtract adjustments for prior months. Attach a separate sheet which explains the

adjustments and showsthe pounds and month(s)for each adjustment.

9. Amount remitted with this report. Amount on line 7 plus or minus amount on line 8. If no

adjustments are made, the amounts on line 7 and line 9 will be the same. $ -

PAYMENT: This report and check made payable to the National Fluid Milk Processor Promotion Board in the amount shown on line 8 must be mailed to the National

Fluid Milk Processor Promotion Board, PO Box 37094, Baltimore, MD 21297-3094, by the last day of the month following the month in which the fluid milk

products were marketed. The postmark date of your remittance envelope will be used to determine the assessment of late-payment charges equal to 1.5% per month of the

amount owed. Please allow time for postal service processing.

CERTIFICATION

I declare under the penalties provided by law that this report 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.

RESPONDING OFFICIAL'S NAME (Please Print) TITLE (Please Print)

SIGNATURE OFRESPONDING OFFICIAL Date

Form DA-20R (Rev. 02/2017) Destroy all previous versions. Note: For inquiries regarding your assessment account, please telephone (301) 656-1200.

NATIONAL FLUID MILK PROCESSOR

PROMOTION PROGRAM

MONTHLY REPORT AND REMITTANCE OF AMOUNT DUE

FOR ALL FLUID MILK PRODUCTS PROCESSED AND

MARKETED COMMERCIALLY IN CONSUMER-TYPE

PACKAGES BY FLUID MILK PROCESSORS

This report is required by 7 CFR 1160.211(a) of the regulations that implement the

Fluid Milk Promotion Act of 1990 (Title XIX, Subtitle H, of the Food, Agriculture,

Conservation, and Trade Act of 1990. Pub. L. 101-624), as amended. Failure to

report or remit amount due can result in a substantial civil penalty. 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 0581-0093. The time required to complete this information collection

is estimated to average 30 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.

Official Use Only
Part A - List of Exempt Fluid Milk Brands 1

If processing fluid milk from brands not marketed at retail by the processor, list such brands in the space below to allow for verification that such brand has sought an

organic exemption.

Name of Exempt Fluid Milk Brands

Form DA-20 (Rev. 02/17) (Reverse)

1 You may attach a separate listing or computer printout showing Part A information if you prefer.

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.