LS-101 Pork Promotion Investment Report

National Research, Promotion, and Consumer Information Programs

LS-101

National Research, Promotion, and Consumer Information Programs - Mandatory

OMB: 0581-0093

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Form Approved. OMB No. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MAKRETING SERVICE

PORK PROMOTION INVESTMENT REPORT
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
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complete this information collection is estimated to average 1 hour 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.
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and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because
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(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.,
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(USE LABEL PROVIDED)

CHECK IF ADDRESS CHANGED
ACCT.#
NAME

CHECK TO ORDER FORMS

ADDRESS
CITY
STATE

ZIP

PHONE
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


File Typeapplication/pdf
File TitleMicrosoft Word - LS-101
AuthorLGallion
File Modified2007-08-08
File Created2007-08-08

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