Appendix B Sample Producer Affidavit

Grade A Permit # (if applicable) _________________

Name   License # (if applicable) _________________

Address  

City   State _________ Zip Code ___________

Name of Farm  

Address (if different)  

City   State _________ Zip Code ___________

Telephone (___) ____________________ Plant Receiving Milk___________________________________________

State of Wisconsin   )

    ) ss:

County of     )

I, __________________________________, as the owner or permit holder responsible for the dairy farm operation identified above, hereby certify as follows:

1. That no animals on the above farm are currently being treated with recombinant bovine somatotropin (rBST), also known as recombinant bovine growth hormone (rBGH);

2. That no animals on the above farm have received rBST treatments within the past 30 days;

3. That I will provide written notice to the buyer of my milk at least thirty (30) days in advance if I intend to use rBST on my dairy cattle; and

4. That I will not sell milk from animals added to my herd if those animals may have received rBST treatment within the previous 30 days.

I declare, under oath, that the above statement is true and correct to the best of my knowledge.

Producer Signature _______________________________,   Subscribed and sworn to before me this ________day of
______________________, 2____.

_________________________________________

        Notary Public

_________________________ County, Wisconsin

My Commission Expires ____________________