P&SP 1400 Packer Inquiry

U.S. DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND STOCKYARDS ADMINISTRATION
PACKERS AND STOCKYARDS PROGRAM

PACKER INQUIRY
PACKERS AND STOCKYARDS ACT, 1921,
AS AMENDED AND SUPPLEMENTED

OMB Control No. 0580-0015
Response is required in order to determine if packer is subject to bonding provision of the Packers and
Stockyards Act, 1921, as Amended and Supplemented (7 U.S.C. 204). Information held confidential (9 CFR
201.96).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB contr ol number for this information
collection is 0580-0015. The time requested to complete this information is estimated to average 1 hours per
response, including the time to review instruction, search existing data sources, gather the data needed, and
complete and review the information collection.

1. REPORT FOR YEAR ENDED
December 31, 20 ___________.
2. IF FIRM OPERATES ON FISCAL YEAR, LIST FISCAL YEAR

SECTION I - GENERAL INFORMATION
3. FIRMS NAME AND ADDRESS (Include ZIP +4 code)

5. TELEPHONE NUMBER

6. FAX NUMBER

4. E-MAIL ADDRESS

7. TYPE OF ORGANIZATION

8. LIST STATE INCORPORATED/
REGISTERED/FORMED
ASSOCIATION
CORPORATION
INDIVIDUAL
9. DATE INCORPORATED/
L.L.C.
REGISTERED/FORMED
L.L.P.
PARTNERSHIP
OTHER ____________________
(Specify)

10. DID ANY CHANGE IN ORGANIZATION TAKE
PLACE DURING THE YEAR?
YES

11. IF "YES," GIVE DETAILS
NO

12. OWNERS, PARTNERS, OFFICERS, AND DIRECTORS

NAME

TITLE

% OF OWNER-SHIP

MAILING ADDRESS (Street and no., City, State, and ZIP +4 Code)

SOCIAL SECURITY NUMBER

The Privacy Act of 1974 requires this Agency to inform applicant that disclosures of social security numbers are optional and that the information sought on this form is required by 9 CFR
201.10. The sole use of the social security number(s) sought on this form is to distinguish between applicants and registrants that have identical or similar names. As this Agency
maintains a large volume of applicants and registrations, applicants are encouraged to supply social security numbers.

SECTION II - COST OF LIVESTOCK PURCHASED
13. TOTAL COST OF ALL LIVESTOCK PURCHASES FOR YOUR ACCOUNT

$___________________________________

SECTION III - PURCHASES AND SALES
14. Does the firm purchase livestock for slaughter?
14 a. Does the firm purchase livestock for slaughter at terminal stockyards or auction markets?

YES

NO

14 b. Does the firm purchase livestock for slaughter from outside the State in which slaughtered?

YES

NO

15 a. Did the firm sell or ship any meat or meat food products outside the State where such meat or meat food products are manufactured or prepared by it?
15 b. Did the firm sell or ship meat or meat food products manufactured or prepared by it to U.S. Government agencies (i.e., military installations,
hospitals, etc.)?
16. Do you operate as a wholesale broker, dealer, or distributor in commerce t o market meat, meat food products, or livestock products in an
unmanufactured form?

YES

NO

YES

NO

YES

NO

NO. OF HEAD

SECTION IV - LIVESTOCK SLAUGHTERED
CATTLE

CALVES

HOGS

SHEEP

17. By the firm for its own account.
18. By the firm for the accounts of others.
19. By others for the firm's account. NOTE: Under remarks (Section VI), list name and
address of each person or firm for or by whom 1,000 head were slaughtered and l ist
whether in answer to IV.B. or IV.C.
P&SP FORM 1400

August 2007

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SECTION V - MEAT AND MEAT FOOD PRODUCTS SOLD
20. TOTAL SALES VALUE OF ALL MEAT AND MEAT FOOD PRODUCTS HANDLED BY FIRM

$______________________________________________ ___

SECTION VI - REMARKS
21. (Use this space for additional information or explanation, making reference to item number. Continue on reverse of form if necessary.)

RETURN COMPLETED FORM TO THE APPROPRIATE REGIONAL OFFICE; SEE
SEPARATE INSTRUCTION FOR INFORMATION.

I certify that this report has been prepared by me or under my direction and to the best of my
knowledge and belief this report correctly reflects the operations of the reporting firm.
22. SIGNATURE (Owner, Partner, or Responsible Officer)
23. DATE

24. TITLE
25. TELEPHONE NO.

The Packers and Stockyards Act provides in part that "Any person who shall willfully make, or cause to be made, any false entry or statement of fact in any report required to be made
under this Act . . . shall be deemed guilty of an offense against the United States, and shall be subject, upon conviction in any court of the United States of competent jurisdiction, to a fine
of not less than $1,000 nor more than $5,000, or to imprisonment."

P&SP FORM 1400

August 2007

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