Fillable Payment Disbursement Form NORTH CAROLINA DEPARTMENT OF AGRICULTURE (Information Technology Services)

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Payment Disbursement Form NORTH CAROLINA DEPARTMENT OF AGRICULTURE (Information Technology Services)

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NORTH CAROLINA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
FOOD & DRUG PROTECTION DIVISION
Animal Feed Program
Payment Disbursement Form
This form is to be used by an Agent submitting a single payment for multiple firms. Please use the
template below to indicate how to disperse funds if paying with a single check or single credit card
payment.
Firm Name*
NC Feed ID
Amount Applied
Total Amount:
$
*Firm name should be the name of the firm that the money will be applied to.
**Please
contact the Animal Feed Registration desk at (919) 733-7366 or
NCFeed.Registration@ncagr.gov
if you have any questions**
Form F_3001 (10/20)
1
Payment Disbursement
0.00
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Payment Disbursement Form NORTH CAROLINA DEPARTMENT OF AGRICULTURE (Information Technology Services)

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Completed 28 January 2021

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