P&SP 1500 Live Poultry Dealer Inquiry

U.S. Department Of Agriculture Grain Inspection, Packers And Stockyards Administration Packers And Stockyards Program	Live Poultry Dealer Inquiry
Section 1 - General Information
1. Name and Address					2. Type of Organization
					 Association  Corporation  Individual				 L.L.C.  L.L.P.  Partnership
					 Other __________________ (Specify)
3a. Telephone No. 3b. Fax No.					5. State Formed: ___________________ Date Formed: ___________________
3c. Cell Phone No.					6. If firm operates on a fiscal year, list fiscal year: From: ______________ To: _________________
4. E-mail Address
7a. Name and Mailing Address of Owners, Officers, Directors, and/or Partners			7b.		7c. Title					7d. % Ownership
Section 2 - Description Of Business
8. The poultry firm is a (check all that apply)  Slaughterer  Broker (live)  Meat Dealer or Broker  Processor  Dealer (live)
Section 3 - Live Poultry Purchases
9a. Did the firm purchase live poultry for slaughter?		 Yes  No		9b. FSIS Establishment No.
10. Did the firm purchase live poultry to sell to a firm that slaughters?  Yes  No
11. Did the firm’s purchases originate outside the state in which it was slaughtered?  Yes  No
12. Total annual live poultry purchases $___________________________
Section 4 - Live Poultry Produced Under Growing Arrangements
13. Did firm obtain poultry using growing arrangements for its own slaughter?						 Yes	 No
14. Did firm sell or contract poultry obtained using a growing arrangement?						 Yes	 No
15. Did obtained poultry originate outside the state in which it was slaughtered ?						 Yes	 No
16. Number of growers with growing arrangements _____________
17. Estimated yearly value of the poultry obtained under growing arrangements annually $____________________
Section 5 - Poultry Product Sales
18. Did the firm manufacture or prepare poultry products and then sell or ship those products outside the state of slaughter?								 Yes			 No
19. Did the firm manufacture or prepare poultry products and then sell or ship those products to the U.S. Government?								 Yes			 No
Section 6 - Poultry Product Sold
20. Total dollar amount sales of poultry products and by-products sold on an annual basis? $_______________
Section 7 – Remarks
21. Use this space for additional information or explanation for any numbered items above, making reference to the item number.

Section 8 - Certification

_________________________________ 22. Signature	______________________________________ 23. Title
________________________________ 24. Date

The Packers and Stockyards Act provides in part that “any person who shall willfully make, or cause to be made, any false entry or statement of fact in any report required to be made under this Act … shall be deemed guilty of an offense against the United States, and shall be subject, upon conviction in any court of the United States of competent jurisdiction, to a fine of not less than $1,000 nor more than $5,000, or to imprisonment …”

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 collection is estimated to average .50 hours 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-1500 August 2007 Page 3 of 3