LS-101 Pork Promotion Investment Report

Form Approved. OMB No. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MAKRETING SERVICE

PORK PROMOTION INVESTMENT REPORT
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sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
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NAME

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ADDRESS
CITY
STATE

ZIP

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Pork Producer Checkoff Investments are shared by national and state organization to conduct pork industry promotion, research and consumer information programs.

MARKET HOG/CULL SOWS/BOARS INVESTMENT
State of Origin

Number of Hogs
HD
HD
HD
HD
HD
HD
HD

Total:

Gross Market Value
$
$
$
$
$
$
$

Promotion Assessment
x .0400 of Gross
x .0400 of Gross
x .0400 of Gross
x .0400 of Gross
x .0400 of Gross
x .0400 of Gross
Total:

$
$
$
$
$
$
$

FEEDER/ISOWEAN/PIG INVESTMENT
State of Origin

Number of Hogs
HD
HD
HD
HD
HD

Total:

Gross Market Value
$
$
$
$
$

Promotion Assessment
x .0400 of Gross
x .0400 of Gross
x .0400 of Gross
x .0400 of Gross
Total:

$
$
$
$
$

SEEDSTOCK INVESTMENT
State of Origin

HD
HD
HD

Total:

DUE:

Number of Hogs

Gross Market Value
$
$
$

15 DAYS AFTER PERIOD ENDING DATE*
1.5% LATE CHARGE PER MONTH WILL BE BILLED

Promotion Assessment
x .0400 of Gross
x .0400 of Gross
Total:

$
$
$

TOTAL AMOUNT OF CHECK
PERIOD COVERED

$
THRU

(month/day)

20
(month/day)

Monthly reporting required on assessments of $25 per month. Assessments less than $25 during each month of a quarter may be reported
quarterly.
I hereby certify under penalty by law that the information contained in this Investment Report is true and accurate.

Signature
Mail this form with the required information to: National Pork Board, P.O. Box 9114, Des Moines, IA 50306
LS-101

Date