P&SP 3001 Annaul Report of Dealer or Market Agency Buying on Commi

					For P&SP Use Only									P&SP Bar Code Only
U.S. Department of Agriculture					ANNUAL REPORT OF DEALER OR MARKET AGENCY BUYING ON COMMISSION
Grain Inspection,
Packers and Stockyards
Administration
Packers and					Instructions: If an item's value is zero, enter "0". If an item does not apply, enter "NA". Upon completion please verify that all items have been answered. Return completed form to the P&SP Central Reporting Unit. See separate instructions for complete information about this report.
Stockyards
Program
										GENERAL INFORMATION - SECTION 1
101			Reporting Period (mm/dd/yy-mm/dd/yy)			a. from									b. to
102			Legal Business Name
103			Business Name (dba)
104			Mailing Address
105			City, State, Zip
106			Physical Address
107			City, State, Zip
108			Contact Name
109			Telephone Number
110			Fax Number
										ORGANIZATIONAL STRUCTURE - SECTION 2
			List owners, officers, partners, and managing members in control of this business
			a. Name									b. Title							c. Percentage Ownership
201
202
203
204
205
206			Type of organization:		Individual			Partnership			Corporation			L.L.C.		L.L.P.	Co-op		Association			Other
207			Is this the same organization type reported last year?									Yes		No
208			Is this business owned or controlled by another business entity?									Yes		No
209			If line 208 is yes, identify the owner/controlling business name and address
210			Does this business own or control other businesses within the livestock-meat sector?												Yes		No
			If line 210 is yes, then provide the names of businesses that you own or control and percentage of control in items 211-214
			a. Name of Business																	b. Percentage of Control
211
212
213
214
215			Do you own or operate a scale on which you weigh livestock purchased?											Yes		No
216			What is the basis of payment made to you for most livestock you sale?											Liveweight			Dressed Weight or Carcass Basis
Your response to this form is required under the Packers and Stockyards Act of 1921 (9 CFR 201.97 and 7 U.S.C. 181-229). 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 information collection is estimated to average 2 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
										BOND INFORMATION - SECTION 3
			Livestock Dealer Activity					a. Cattle & Calves			b. Hogs			c. Sheep & Goats			d. Horses & Mules			e. Total (a+b+c+d)
301			Cost of livestock purchased on a dealer basis for registrant's account					$			$			$			$			$
302			Number of head of livestock purchased on a dealer basis for registrant's account
			Livestock Bought on Commission					a. Cattle & Calves			b. Hogs			c. Sheep & Goats			d. Horses & Mules			e. Total (a+b+c+d)
303			Cost of livestock bought on commission for the account of others regardless of who paid for the livestock					$			$			$			$			$
304			Number of head of livestock bought on commission for the account of others regardless of who paid for the livestock
305			What was the dollar value of livestock dealer and BOC purchases in your highest fiscal year quarter?														$
									CLEAREE AND CLEAROR DESIGNATIONS - SECTION 4
401			Are you a clearee (cleared by another business for your livestock purchases)?											Yes		No
402			If you checked yes in item 401, provide the name of the clearing agent:
403			Are you a clearor (provide clearing services for clearees)?											Yes		No	If yes provide information for items 404-412
			Clearee's Name as Registered											Gross Value of Livestock Purchased
404														405	$
406														407	$
408														409	$
410														411	$
			Total Livestock Purchases of all Clearees											412	$
										BALANCE SHEET - SECTION 5
			All clearors and dealers whose line 301e plus 303e plus 412 total is below a specified $ amount (see instructions) do not need to complete Sections 5 and 6.
Assets
	Current Assets
		Cash (Enter overdrafts under Current Liabilities - line 515)																	501	$
		Temporary Cash Investments (Marketable Securities, Certificates
			of Deposit, Commercial Paper, etc.)																502	$
		Accounts Receivable (Due in 1 Year or Less)																	503	$
		Notes and Loans Receivable (Portion due in 1 Year or Less)																	504	$
		Inventory
			Livestock											505	$
			Other Inventory											506	$
		Total Inventory																	507	$
		Other Current Assets																	508	$
	Total Current Assets																		509	$
	Long-Term Assets
		Investments												510	$
		Property, Plant, & Equipment net of Depreciation and Amortization												511	$
		Other Long-Term Assets												512	$
	Total Long-Term Assets																		513	$
Total Assets																			514	$
Continuation of Section 5 Balance Sheet.
Liabilities and Net Worth
Liabilities
	Current Liabilities
		Bank Overdraft																	515	$
		Accounts Payable
			Livestock Payables											516	$
			Other Payables											517	$
		Total Accounts Payable																	518	$
		Notes and Loans Payable (Demand Notes and Portion of
			Long-Term Notes due in One Year or Less)																519	$
		Other Current Liabilities																	520	$
	Total Current Liabilities																		521	$
	Long-Term Liabilities (Due after One Year)																		522	$
Total Liabilities																			523	$
Total Net Worth																			524	$
Total Liabilities and Net Worth (Equals Total Assets)																			525	$
									INCOME STATEMENT - SECTION 6
			All clearors and dealers whose line 301e plus 303e plus 412 total is below a specified $ amount (see instructions) do not need to complete Sections 5 and 6.
Income Statement
	Gross Dealer Profit (+) or Loss (-)																		601	$
	Buying Commission																		602	$
	Other Income																		603	$
		Total Income																	604	$
		Total Expenses																	605	$
	Net Profit (+) or Loss (-) before Income Taxes																		606	$
										CERTIFICATION - SECTION 7
Under the Packers and Stockyards Act any person who willfully makes, or causes any false entry or statement of fact in this report shall be deemed guilty of offense against the United States, and be subject to a fine of $1,000 to $5,000, or to imprisonment for a term of not more than 3 years, or to both fine and imprisonment.
I certify that this report has been prepared by me or under my direction, and to the best of my knowledge and belief correctly reflects reporting entity operations.
701 Print Name												702 Signature (Must be signed by a person listed on 201-205)
703 Phone Number								704 Date				705 Title
Submitted information is confidential (9 CFR 201.96). Failure to report will result in forfeiture to the United States $110 per day until report receipt 7 (U.S.C. 222).
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.