28 BULLETIN 559, U. 3. DEPABTMEXT OF AGBICTTLTTJBE. 



0£lce of Itlarkets and Rural Organization. Creamery System Form >7o. 5. 



No. 



Creamery Co., 



Place 191.. 



Pay to the order of $ 



Dollars. 



Creamery Co. 



By 



Bank 



Line of perforation. 



petaeh statement before presenting for payment. 

 'atrcns No If incorrect, return at once vritii check for adjustment. 







Test. 



Pounds | 

 butter Price. 

 fat. 



Amount. 



Deductions. 









F'.ae. 



Lbs. but- i Amount 

 ter. ! of butter. 



Hauling. 



Sundries. 













1 











































• 





































" | 1 1 "'■' 















Total. 



I I 



Amount of check, $. 

 Amount of overdraft, $. 



