Regulations and Related Reporting and Recording Requirements - Packers and Stockyards Programs-Business

Instructions to Complete

Weigher’s Acknowledgement and Agreement

for Weighing Live Poultry or Feed

Form P&SP-4100

Mail the completed form to the appropriate regional office of the Packers and Stockyards Program as listed below. The states covered by each regional office are listed below its address.

Regional Offices of the Packers and Stockyards Program Grain Inspection, Packers and Stockyards Administration
Eastern Regional Office Suite 230 75 Spring Street Atlanta, GA 30303-3308 Telephone: (404) 562-5840 FAX: (404) 562-5848 e-mail: [email protected]	Western Regional Office 3950 Lewiston St., Suite 200 Aurora, CO 80011-1556 Telephone: (303) 375-4240 FAX: (303) 371-4609 e-mail: [email protected]	Midwestern Regional Office Room 317 210 Walnut Street Des Moines, IA 50309-2110 Telephone: (515) 323-2579 FAX: (515) 323-2590 e-mail: [email protected]
States Covered	States Covered	States Covered
AL, AR, CT, DC, DE, FL, GA, LA, MA, MD, ME, MS, NC, NH, NJ, NY, PA, RI, SC, TN, VA, VT, WV	AK, AZ, CA, CO, HI, ID, KS, MT, NM, NV, OK, OR, TX, UT, WA, WY	IA, IL, IN, KY, OH, MI, MO, MN, ND, NE, SD, WI

If you have any questions regarding this form, please contact the appropriate regional office of the Packers and Stockyards Program listed above.

Line No.	Subject	Instruction
1	Name	Enter name of person signing Weigher’s Acknowledgement and Agreement.
2	Employer	Enter name of company weigher is employed by.
3	City	Enter city where weigher will be weighing poultry.
4	State	Enter state where weigher will be weighing poultry.
5	Weigher Signature	The weigher must sign the form in front of a witness.
6	Witness Signature	A witness must sign the form after witnessing the weigher’s signature.
7	Date	Enter date that Weigher’s Acknowledgement and Agreement was signed and witnessed.

P&SP-4100-i August 2007 Page 1 of 1