"Agricultural Producers Complaint/Claim Form" - New York

Agricultural Producers Complaint/Claim Form is a legal document that was released by the New York State Department of Agriculture and Markets - a government authority operating within New York.

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Download "Agricultural Producers Complaint/Claim Form" - New York

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ANDREW M. CUOMO
RICHARD A. BALL
Governor
Commissioner
AGRICULTURAL PRODUCERS COMPLAINT/CLAIM FORM
Claimant
Dealer
Name
Name
_________________________________________
_________________________________________
Address
Address
_______________________________________
______________________________________
AGAINST
_______________________________________________
_______________________________________________
County:
County:
______________________________________
______________________________________
Phone No. _____________________________
Phone No. _____________________________
Fax No.: ______________________________
Fax No.: ______________________________
E-Mail:
E-Mail:
______________________________________
_______________________________________
The undersigned hereby files with the Commissioner of Agriculture and Markets this complaint/claim against the above
dealer. Claimant, deposes and says: That he is a New York State Agricultural Producer and a creditor of the above named
person doing business as a dealer (includes commission merchant, net-return dealer, broker and processor); that said dealer
was and still is justly indebted to said claimant in the sum of $________________ DOLLARS for farm products produced
within this State and grown by the claimant as listed below and delivered to or received by the dealer at (Business Address):
_____________________________________________________________________________
DATE OF
DATE TO
AGREED PRICE
TRANSACTION
BE PAID
PRODUCT
QUANTITY
PER UNIT
AMOUNT
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_______________________________________________________________________________________________________
BALANCE DUE CLAIMANT $__________________
Are there any unpaid transactions that are not listed on this claim form?  Yes  No
If yes, what were the transaction
dates and the amounts unpaid? _____________
_________________________________________________
_________________________________________________________________________________________________
At the time the claim transaction(s) took place, did you have a written agreement in place, which authorized payment beyond
30 days?  Yes
 No If yes, attach a copy of the agreement.
Have you provided a written notice to the dealer to preserve your trust benefit?  Yes
 No
If yes, when was it
provided to the dealer? _________________________
(Month, Day, Year)
Attached is documentation including contracts, written agreements, receipts, accounts of sales, notices of sales, a statement
describing the details of the claim, protested checks, if any, and any other papers relating to the shipment of said farm
products with said dealer.
“I understand that the statements made in this claim will be accepted for all purposes as the equivalent of an affidavit and
that any false statements made herein, may be punishable as a misdemeanor under the provisions of Section 210.45 of the
Penal Law of the State of New York.”
__________________________________________
Office Use Only
Signature
Status
Date
Auditor
__________________________________________
Case No. ________
Title
1. License Status
Yes
No
______
_______
Social Security Number ______________________
2. Complaint/Claim Resolved
______
_______
or
3. Producer Audit
______
_______
Federal ID Number __________________________
4. Dealer Audit
______
_______
__________________________________________
Date
Division of Agricultural Development │ 10B Airline Dr. Albany, N.Y., 12235│Phone 518-457-4383 Fax 518-457-2716 │www.agriculture.ny.gov
ANDREW M. CUOMO
RICHARD A. BALL
Governor
Commissioner
AGRICULTURAL PRODUCERS COMPLAINT/CLAIM FORM
Claimant
Dealer
Name
Name
_________________________________________
_________________________________________
Address
Address
_______________________________________
______________________________________
AGAINST
_______________________________________________
_______________________________________________
County:
County:
______________________________________
______________________________________
Phone No. _____________________________
Phone No. _____________________________
Fax No.: ______________________________
Fax No.: ______________________________
E-Mail:
E-Mail:
______________________________________
_______________________________________
The undersigned hereby files with the Commissioner of Agriculture and Markets this complaint/claim against the above
dealer. Claimant, deposes and says: That he is a New York State Agricultural Producer and a creditor of the above named
person doing business as a dealer (includes commission merchant, net-return dealer, broker and processor); that said dealer
was and still is justly indebted to said claimant in the sum of $________________ DOLLARS for farm products produced
within this State and grown by the claimant as listed below and delivered to or received by the dealer at (Business Address):
_____________________________________________________________________________
DATE OF
DATE TO
AGREED PRICE
TRANSACTION
BE PAID
PRODUCT
QUANTITY
PER UNIT
AMOUNT
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_______________________________________________________________________________________________________
BALANCE DUE CLAIMANT $__________________
Are there any unpaid transactions that are not listed on this claim form?  Yes  No
If yes, what were the transaction
dates and the amounts unpaid? _____________
_________________________________________________
_________________________________________________________________________________________________
At the time the claim transaction(s) took place, did you have a written agreement in place, which authorized payment beyond
30 days?  Yes
 No If yes, attach a copy of the agreement.
Have you provided a written notice to the dealer to preserve your trust benefit?  Yes
 No
If yes, when was it
provided to the dealer? _________________________
(Month, Day, Year)
Attached is documentation including contracts, written agreements, receipts, accounts of sales, notices of sales, a statement
describing the details of the claim, protested checks, if any, and any other papers relating to the shipment of said farm
products with said dealer.
“I understand that the statements made in this claim will be accepted for all purposes as the equivalent of an affidavit and
that any false statements made herein, may be punishable as a misdemeanor under the provisions of Section 210.45 of the
Penal Law of the State of New York.”
__________________________________________
Office Use Only
Signature
Status
Date
Auditor
__________________________________________
Case No. ________
Title
1. License Status
Yes
No
______
_______
Social Security Number ______________________
2. Complaint/Claim Resolved
______
_______
or
3. Producer Audit
______
_______
Federal ID Number __________________________
4. Dealer Audit
______
_______
__________________________________________
Date
Division of Agricultural Development │ 10B Airline Dr. Albany, N.Y., 12235│Phone 518-457-4383 Fax 518-457-2716 │www.agriculture.ny.gov