LICENSEE / DISTRIBUTOR : Remit to : Yong Inouye Department of Agriculture - F & N405 South 21st Street

Sparks, Nevada 89431

PH: (775)353-3607 Fax: (775)353-3749

License # Month: Year :

CONVERSION FACTORS

ASSESSMENT CALCULATION : (X) ASSESSMENT = TOTAL

SOUTHERN NORTHERN TOTAL ASSESSMENT

1 per Lb

2 per Lb

3 Ice Cream/Nov per Gal

4 Frozen Mix per Gal

5 SUB-TOTAL

6 ADJUSTMENTS (Attach explanation)

LATE FEES : Per N.R.S. 584.649.3, the department shall charge, as a penalty for late payment, the amount of $10, or

10% of the total amount due, but remaining unpaid, whichever is greater.

PAYMENTS ARE DUE ON THE 20TH OF THE MONTH. TOTAL ASSESSMENT DUE :

Signature:

Print Name :

Check No : Title:

Amount : Telephone No: Date:

Postmark Date : Email :

Please retain photocopy and submit original form to the Department of Agriculture.

STATE OF NEVADA

Department of AgricultureFood & Nutrition

DAIRY PRODUCTS REMITTANCE REPORT

Weight Conversion

RATE

Pounds

Yogurt Packs

4 oz = .25 lb6 oz = .375 lb16 oz = 1.0 lb

4 pk 6/4oz = 6 lb 6pk 4/4oz = 6 lb

Pounds

Gallons

Gallons

I certify that this report is correct to the best of my knowledge.

Department Use Only

7

Yogurt

Cottage Cheese

Revised 07/20/2017 DC-2 Remittance Report

Fax #: