Beef - Private Treaty Sales Check-Off Investment

OMB 0581-0093

Beef Promotion and Research Program
PRIVATE TREATY SALES CHECK-OFF INVESTMENT FORM
Information is required by (7 CRF 1260.201). Failure to report can result in a fine. Information is held confidential (7 CRF 1260.203).

Today’s Date
Seller’s Name

Buyer’s Name

Address

Address

City

State

Zip

City

Seller’s Signature

State

Zip

Buyer’s Signature

Both the seller & the buyer are responsible for making sure that the $1 per head assessment is collected and remitted to
the Beef Promotion & Research Board.

Total Number of Cattle Sold:

Date of Sale

X

$1.00 per Head

=

Person remitting assessment form:

Seller

Buyer

State of Origin
*If the cattle purchased came from another state within the last 30 days, indicate from which state the cattle were purchased.

Send Report and Remittance to:

See QSBC Remittance Addresses
for address of State Beef Council

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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age,
disability, sexual orientation, marital or family status, political beliefs, parental status, or protected genetic information. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten
Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and
employer.