LS-78 Certification on Non-Producer Status

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.

FORM APPROVED - OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

CERTIFICATION OF NON-PRODUCER STATUS (FOR THE SELLER)
Failure to pay the lamb checkoff is a violation of federal law. 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. § 1001).
I CLAIM NON-PRODUCER STATUS ON

HEAD OF LAMBS FOR A TOTAL LIVE WEIGHT OF

WHICH I AM RESELLING

(number)

ON

(date)

BUYER'S NAME AND ADDRESS

I CERTIFY upon reselling these lambs in compliance with 7 CFR 1280.217 that I have purchased these lamb to facilitate the transfer of ownership
of these lambs to a third party and I am reselling these lambs no later than 10 days from the date I purchased them; or that I have purchased these
lambs and upon transfer shall receive only a sales commission or a service fee which was established prior to my purchase of the lambs.
I (the reseller) further certify that when I purchased these lambs, collected the assessment due and passed it on to the subsequent
purchasers.

(Check applicable box(es))
1. I received a Certification of Non-Producer Status from the person I purchased these lambs from; or
2. I purchased these lambs in a transaction in which I was not responsible for paying an assessment.

Persons who owns these lambs at the time of sale and is claiming Non-Producer status.
RESELLER'S NAME:
SOCIAL SECURITY# OR TAX ID#:
ADDRESS:
CITY:
STATE/ZIP:
SIGNATURE OF RESELLER:
The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The
authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110
Stat.1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification
Number (TIN) or Employer Identification Number (EIN) is mandatory, and will be used to determine affiliation or entity identification.
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 2 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. INFORMATION IS REQUIRED BY (7 CFR
1280.407) Information is held confidential (7 CFR 1280.227).
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.

LS-78 (02-11)

(Destroy previous editions.)