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 ____________________
