QID 050801 Prices Paid for Screener

PRICES PAID FOR SCREENER
			OMB No. 0535-0003 Approval Expires: 3/31/2013 Project Code: 171 QID: 050801
						NATIONAL AGRICULTURAL STATISTICS SERVICE

Field Office U.S. Department of Agriculture, Rm 5030, South Building 1400 Independence Ave., S.W. Washington, DC 20250-2000 Phone: 1-800-727-9540 Fax: 202-690-2090 E-mail: [email protected]

Please make corrections to name, address and ZIP Code, if necessary.

Information requested on this report will be used to select a sample of businesses from which to obtain data on the cost of agricultural inputs. Your firm is included in a small sample and your report is needed to insure accurate estimates. Under Title 7 of the U.S. Code and CIPSEA (Public Law 107-347), facts about your operation are kept confidential and used only for statistical purposes in combination with similar reports from other producers. Response is voluntary. However, your cooperation is very important in order to estimate these prices accurately.

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 is 0535-0003. The time required to complete this information collection is estimated to average 10 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.

Please mail your report promptly in the enclosed postage paid envelope. Thank you for your cooperation.

Fuel

1. Does this operation sell Fuel to farmers in the U.S.?

Yes. No.

Feed 2 Does this operation sell Feed to farmers in the U.S.?
Yes No.
Seed 3 Does this operation sell Seed to farmers in the U.S.?
Yes No.
Fertilizer and Chemicals 4 Does this operation sell Fertilizers or Agricultural Chemicals to farmers in the U.S.?
Yes. No.

Over

Machinery

5 Does this operation sell New Farm Machinery to farmers in the U.S.?

Yes. No.

Type of Operation

6 Does this business operate at a single location or multiple locations?

One location. Multiple locations.

Multiple Locations. Please complete the following information if you operate at multiple locations.

List all addresses where this operation does business.

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Considering all the locations listed, how would you prefer to report?

Contact each site individually.

Headquarters reports for all locations on one report. Contact: ___________________________

Headquarters reports for all locations on separate reports. Contact: ___________________________

Reported by: _______________________ Date______________ Phone: (______) ______ - ___________