LS-378 Monthly Report Collecting Handler

REPRODUCE LOCALLY. Include form number and edition date on all reproductions							FORM APPROVED – OMB NO. 0581-NEW
UNITED STATES DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SORGHUM, PROMOTION, RESEARCH, AND INFORMATION PROGRAM A program of promotion, research, and consumer information designed to strengthen the sorghum industry.					Note: Information is required by 7 CFR 1290.116. Failure to report can result in a fine. Information is held confidential (7 CFR 1290.127). 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-NEW. The time required to complete this information collection is estimated to average 0.25 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completinand reviewing the collection of information. Privacy Act Notice Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to identify entities that collect and remit assessments. 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.
REPORT AND REMITTANCE OF AMOUNT COLLECTED AND DUE ON SORGHUM PURCHASED
NAME AND ADDRESS (include P.O. Box or Street, City, State, and ZIP)						Federal Identification Number
						State Grain Dealer License Number (if applicable)
						County
						Business Telephone (include area code)
The report and assessments must be remitted (postmarked) by the last day of the month following the end of the collection period. Late Payments are subject to a 2% per month late payment charge. Must be remitted by _____________________. The following report is a report on sorghum purchased and the net market value paid for such purchases for the period commencing _________________and ending ______________________.							“Net market value” is the value found by multiplying the net market price (the sales price or other value, per volumetric unit, received by a producer after adjustments for any premium or discount based on grading or quality factors) by the appropriate quantity, bushels or tons, of sorghum. “Net market value” may also mean the minimum value in a production contract received by a sorghum producer.
STATE OF ORIGIN	NUMBER OF BUSHELS PURCHASED	NUMBER OF BUSHELS ASSESSED	NET MARKET VALUE OF ASSESSED BUSHELS				RATE	TOTAL
	NUMBER OF TONS PURCHASED	NUMBER OF TONS ASSESSED	NET MARKET VALUE OF ASSESSED TONS
							x.006=	$
							x.035=	$
							x.006=	$
							x.035=	$
							x.006=	$
							x.035=	$
							x.006=	$
							x.035=	$
							x.006=	$
							x.035=	$
							x.006=	$
							x.035=	$
* NOTE: If remitting assessments past due date, calculate the 2% mandatory late payment (compounded monthly). Total Assessments x.02 = Late Payment							TOTAL ASSESSMENTS =
							* LATE PAYMENT =
							TOTAL REMITTANCE =
SEND THIS REPORT AND A CHECK IN THE TOTAL AMOUNT SHOWN ABOVE TO:							OFFICE USE ONLY
							PENALTIES: You may, by law, be fined up to $10,000, imprisoned up to five years or both for knowingly or willfully making false statements within this document (18 U.S.C., Section 1001).
CERTIFICATION STATEMENT
I declare, under the penalties provided by law, that this report has been examined by me; and to the best of my knowledge and believe is a true, correct and complete report.
NAME/TITLE (Print or type)				SIGNATURE					DATE
LS-378