No Form Number Beef Monthly Report and Remittance for Cattle Purchased

OMB 0581-0093

Beef Promotion and Research Board
A program designed to increase demand for beef

Information is required by (7 CFR 1260.201). Failure to report can result in a fine. Information is held in confidential (7 CFR 1260.203).

MONTHLY REPORT AND REMITTANCE FOR ALL CATTLE PURCHASED OR MARKETED IN THE MONTH OF:

/
I.D. NO.:

Company:
Address:
City:
Business Phone#:
This report and assessments must be remitted by the fifteenth day of the month following the month in which
the cattle were marketed. Late payments are subject to a 2% per month late payment charge.
Instructions: Please provide the following information on all cattle you or your company marketed by completing the following table:

CATTLE AND CALVES
State of Origin

Total Number of Head Marketed

Number of Head NOT Assessed

Number of Head per State Assessed

-

=

-

=

-

=

-

=

-

=

-

=

-

=

-

=

-

=

TOTAL

Send this report and a check payable to :
See QSBC Remittance Addresses on this web site

TOTAL

TOTAL

x $1.00/Head
Amount Due

$

I declare under the penalties provided by law, that this report has been examined by me and to the best
of my knowledge is a true, correct and complete report. I also certify that I am authorized to sign this report.

DATE

TITLE (PRINT)

RESPONDING OFFICIAL'S NAME (PRINT)

SIGNATURE

CHECK TO ORDER FORMS
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0581-0093. The time required to complete this information collection is estimated to average 1 hour per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital
status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance
program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.)
should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue,
S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Forward Original with Remittance. Retain copy for your records.