Destination Data for The
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DESTINATION VERIFICATION FOR THE DELIVERY OF USDA COMMODITIES
Name of State Agency: Kentucky Department of Agriculture, Division of Food Distribution
Name of Processor:
Federal Establishment #:
Facility name and address for the RECEIPT of USDA commodity and / or commodities (specify USDA commodity name and code i.e. Large Chickens A 522):
Contact Person:
Email:
Telephone Number (include area code):
Fax Number (include area code):
Plant location, if different from the facility listed above. If processing at more than one plant, please specify USDA commodity and end product for each plant location:
Contact Person:
Email:
Telephone Number (include area code):
Fax Number (include area code):
Signature of the Authorized Representative of the Processor Date Signed
ACDA 10/06