Dairy Farm Tax Credit Program Fill Out Form

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					             Massachusetts Department of Agricultural Resources
Dairy Farmer Tax Credit Program       2010 Monthly Milk Production Report

Instructions: Please complete the requested information below. This document is to disclose your monthly milk
production subject to verification by the Massachusetts Department of Agricultural Resources. An Eligible Taxpayer
shall submit a monthly milk production report not later than the last day of the next ensuing month except for the month
of December, which shall be submitted not later than the fifteenth day of January. This form may be faxed or emailed.

Name:                                                                Farm Name:
Certificate of                                                       Phone
Registration Number:                                                 Number:
Name(s) of cooperative or handler                                        Producer
who markets or purchases milk:                                           Number:


Eligible Milk Production: Eligible milk production includes all verifiable milk produced on the farm minus
unmarketable milk, e.g. three-out-of-five, positive for antibiotics, or milk produced under a suspended or revoked
Certificate of Registration. For milk marketed to someone other than a cooperative or milk handler, please provide
documents verifying marketable milk. Complete the milk production schedule below or attach a separate sheet showing
the same information.

                                     Calendar Year 2010 Eligible Production (Pounds)

                                           January

                                           February

                                            March

                                            April

                                            May

                                            June

                                             July

                                           August

                                          September

                                           October

                                          November

                                          December

                                                      Total
                                                              0.00



Send completed forms to:                                Laura J. Maul
                                     Massachusetts Department of Agricultural Resources
                                    Attn: Massachusetts Dairy Farmer Tax Credit Program
                                               251 Causeway Street, Suite 500
                                                     Boston, MA 02114
                                           Phone: 617-626-1739 Fax: 617-626-1850
                                                   Laura.Maul@State.ma.us