P&SP 4000 Weigher's Acknowledgement & Agreement - Livestock

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

PSP4000.DOC

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

OMB: 0580-0015

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OMB Control No. 0580-0015

U.S. Department of Agriculture

Grain Inspection, Packers and Stockyards Administration

Packers and Stockyards Program

Weigher’s Acknowledgement

and Agreement

for Weighing Livestock



I, _____________________________________________________________________,

(1) Weigher’s Name


employed by __________________________________________________________________,

(2) Weigher’s Company Name


at __________________________________________, ______________________, as a weigher

(3) City (4) State


of livestock, have read and received the Instructions for Weighing Livestock issued under the authority of the Packers and Stockyards Act, 1921, as amended and supplemented. I agree to fully comply with the Instructions. I am aware that it is an offense against the United States to willfully make any false entry of weight or other information on a scale ticket or other record kept by my employer.


(5) Signature of Weigher:





(6) Signature of Witness:





(7) Date:


The employer of the weigher must: Send one copy of the agreement to the Regional Office of the Packers and Stockyards Program, Grain Inspection, Packers and Stockyards Administration, USDA.


Retain one copy for the weigher named on this agreement.

Response is required to acknowledge receipt of Instructions for Weighing Livestock and to show that weigher has read and agrees to follow the instructions (9 CFR 201.73-1). Information held confidential (9 CFR 201.96).

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 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

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.


Form P&SP-4000 August 2007 Page 2 od 2

File Typeapplication/msword
AuthorIRM
Last Modified Bycmgrasso
File Modified2008-10-09
File Created2007-07-25

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