P&SP 5000 Reparation Complaint

OMB CONTROL NO. 0580-0015

U.S. Department of Agriculture Grain Inspection, Packers and Stockyards Administration Packers and Stockyards Program	Reparation Complaint Before the Secretary of Agriculture
This form may be used to file complaint for reparation within 90 days after cause of action accrued in accordance with Section 309(a) of the Packers and Stockyards Act, 1921, as amended and supplemented (7 U.S.C. 210(a)).

1. Name(s) and Address(s) of Complainant(s)

v.

2. Name(s) and Address(s) of Respondent(s)

The following complaint is filed pursuant to section 309(a) of the Packers and Stockyards Act, 1921, as amended and supplemented. (7 U.S.C. 210(a)).

3. Date of Transaction: __________________ 4. Amount Claimed: $__________________

5. Name of Business and Address where transaction occurred:

6. Briefly describe the transaction involved, including the terms of the contract(s) or agreement(s) and the alleged violation(s). Attach all supporting documents and evidence.

7. Itemize and explain how you calculated amount claimed.

8. Date: _______________ 9. Signature(s) of Complainant(s): _____________________________

If space is insufficient, continue on separate paper and attach.

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 control number for this information is 0580-0015. The time required to complete this collection is estimated to average .50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Form P&SP-5000 August 2007 Page 2 of 1