Arizona Department of Agriculture (ADA)
Central Licensing Section
1688 W. Adams
Phoenix, AZ 85007
For ADA/ESD Use Only
Check # _________________________
Check Date _______________________
Check Amount _____________________
Phone: (602) 542-3578 Fax: (602) 542-0466
Date Received _____________________
Statement of Sales of Commercial Feeds and Formula Feeds
By:
A Report must be filed and $2.00 minimum fee paid
each quarter even if tonnage is zero. A penalty will
be assessed if reported after date listed.
A. Complete this form, sign on reverse side at the bottom and return with fee to the above address.
F. If you are passing on responsibility for payment, check box and complete reverse side.
A report MUST
be filed and $2.00 minimum paid even if tonnage is zero.
C. Multiply amount in"TOTAL TONS" box above by $0.20 per ton (Note: $2.00 is the minimum).
E. Add Line C and Line D for TOTAL FEES DUE . . . . . . . . . . . . . . . . . . . . . . .
$_____________
$_____________
$_____________
(Passing on Products)
GENERAL INSTRUCTIONS :
B. Fill in the chart below and add up total tonnage.
DETAIL OF MATERIALS COVERED BY ABOVE FEES
MIXED FEEDS
WHOLE TONS
BAGS BULK TOTAL
MATERIALS
WHOLE TONS
BAGS BULK TOTAL
ABeef Cattle Feeds Alfafa Products Q
BBeef Cattle Supplements Animal By-Products R
CDairy Cattle Feeds Beet Pulp S
DDairy Cattle Supplement Cottonseed Products T
ECalf Feeds & Supplements Cottonseed Products,Ammoniated U
FFish Feeds Cottonseed, Whole Ammoniated V
GHorse Feeds Grain By-Products W
HMineral Feed/Supplement Molasses Products X
IMixed Grains Non-protein Nitrogen Products Y
Pet Foods J Oil Seed Meal (not cottonseed) Z
Poultry Feeds/Supplement K Recycled Animal Waste Products AA
LRabbit Feeds Salt BB
MSheep & Goat Feeds Screening CC
NSwine Feeds/Supplements
Miscellaneous
DD
OVitamin Feeds/Supplements
Other (specify)
MM
PWild Bird/Pigeon Feeds
Ratites
TOTAL TONS
of 10% of Line C above. (Note: The minimum late penalty is $10.00) . . . . . . . . . .
Line #____________________________
LATE FEE applies if postmarked more than 30 days
past due
DUE DATE is the
15th Day of Succeeding Quarter
______________________________________________
Distributed during quarter ending _________________________
______________________________________________
______________________________________________
______________________________________________
Quarterly Tonnage Report - ____________ Quarter
D. Enter zero unless postmarked more than 30 days past due, otherwise enter LATE PENALTY"
