No Form Number Certification of Producer Directed Payment of Cattle Ass

OMB 0581-0093 000001

BEEF PROMOTION AND RESEARCH BOARD

CERTIFICATION OF PRODUCER DIRECTED PAYMENT OF CATTLE ASSESSMENTS

FAILURE TO PAY THE BEEF CHECKOFF IS A VIOLATION OF FEDERAL LAW (7 U.S.C. 2901 et sea.). This form must be properly completed and signed to be valid. You may by law be fined up to $10.000, imprisoned up to five years, or both for knowingly or willfully making false statements within this document (18 U.S.C. p 1001).

Date

Producer’s Name

SSN or TIN:

Address

City

State

Zip

Destination Facility

Address

City

State

I am electing to direct payment of and remit assessments in the amount of

$

to the Qualified State Beef

Council (QSBC) of

, my state of residence, on

head of cattle that I have produced and am

State

Head

transporting under retained ownership on

to a feedyard or similar location in the state of

Date

State

I certify that these cattle are of my own production; I am transporting these cattle under retained ownership in compliance with 7 C.F.R. § 1260.311 to a feedyard or similar location in another state; and these cattle shall remain in the feedyard or similar location for a period of not less than 30 days.

I further certify that, upon remitting the producer directed assessment on these cattle, I shall send a copy of this certification form to my QSBC. I understand that a copy of this .Certification of Producer Directed Payment of Cattle Assessments" must be provided to the purchaser (collecting person) at the time of sale to document that the $1 per head assessment has been paid or I will be required to pay the assessment again.

Signature of Owner (Producer)

Composite groups of cattle: (use if cattle are divided) These cattle were divided into separate groups and sold as follows:

Buyer/Date Sold/Head

Buyer/Date Sold/Head

Buyer/Date Sold/Head

Buyer/Date Sold/Head

Buyer/Date Sold/Head

Buyer/Date Sold/Head

Buyer/Date Sold/Head

Buyer/Date Sold/Head

Signature of Feeder

Collection of your social security number is authorized by Executive Order 9397 and will be used only for the purpose of positive identification. Furnishing this information is voluntary. 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 0581-0093. The time required to complete this information collection is estimated to average 12 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. 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.

FORWARD WHITE COPY WITH REMITTANCE.

SEND YELLOW COPY WITH CATTLE.

RETAIN PINK COPY FOR YOUR FILES.

GREEN COPY FOR FEEDERS FILES.