QID 050801 Prices Paid Screener

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Project Code 171 QID 050801		OMB No. 0535-0003: Approval Expires 12/30/2009
	PRICES PAID SCREENER				NATIONAL AGRICULTURAL STATISTICS SERVICE
Please make corrections to name, address and Zip Code, if necessary. Answer yes or no to all of the following –				U.S Department of Agriculture P.O. Box 1148 Cheyenne, WY 82003-1148 1-888-424-7828 Fax: 307-432-5598 E-mail: [email protected]
			Information requested on this report will be used to select a sample of businesses from which to obtain data on the cost of agricultural inputs. Your voluntary cooperation is needed to ensure that all producers are represented in this state and national survey. As always, your response to this survey is confidential. Please return your report in the enclosed postage paid envelope. Thank you for your cooperation. The NASS Agricultural Prices release may be viewed at: http://usda.mannlib.cornell.edu/MannUsda/viewDocumentInfo.do?documentID=1002

Fuel

1. Does this operation sell Fuel to farmers in the U.S.?

Yes. No.

Feed 2 Does this operation sell Feed to farmers in the U.S.?
Yes No.
Seed 3 Does this operation sell Seed to farmers in the U.S.?
Yes No.
Fertilizer and Chemicals 4 Does this operation sell Fertilizers or Agricultural Chemicals to farmers in the U.S.?
Yes. No.
Machinery 5 Does this operation sell New Farm Machinery to farmers in the U.S.?
Yes. No.
Type of Operation 6 Does this business operate at a single location or multiple locations?
One location. Multiple locations.
Multiple Locations. Please complete the following information if you operate at multiple locations.
List all addresses where this operation does business. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Considering all the locations listed, how would you prefer to report?
Contact each site individually.
Headquarters reports for all locations on one report. Contact: _____________________________
Headquarters reports for all locations on separate reports. Contact: _____________________________

Additional Comments:
Reported by: ____________________________________	Phone (______) ______________	9910 Date	MM DD YY _ _ _ _ _ _

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 0535-0003. The time required to complete this information collection is estimated to average 5 minutes 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.