P&SP 2110 Proof of Claim Under Surety Bond - Clause No. 1

OMB CONTROL NO. 0580-0015

U.S. Department of Agriculture Grain Inspection, Packers and Stockyards Administration Packers and Stockyards Program

Proof of Claim Under: Surety Bond, (Clause 1) Trust Fund Agreement, (Clause 1) Trust Agreement, (Clause 1) Issued Under Provisions of The Packers and Stockyards Act, 1921, as Amended and Supplemented

State of (1) ________________________________________

County (2) ________________________________________

As the undersigned, I, (3) ___________________________________________________

(full name of claimant)

Of (4) __________________________________ (5) _____________________________

(complete mailing address) (phone: home, cell)

________________________________________________________________________

(other contact information: fax number, email address)

being duly sworn, depose and state:

I make this claim to (6) ____________________________________________________

(name of trustee or surety)

Select One:

• under the bond issued by the (7a) ___________________________________________________________

(name of surety company)

• under the Trust Fund Agreement with security held by (7b) ____________________________________________________________

(depository, if one named)

• under the Trust Agreement with letter of credit held by (7c) ____________________________________________________________

(name of trustee)

on behalf of (8) ___________________________________________________________

(full name and address of principle named in the instrument checked above)

________________________________________________________________________

in the amount of (9) _____________, which is the proceeds from l ivestock sold by

(10) ______________________________________________________

(full name and address of selling agency/registrant) Clause 1

for my account on a commission basis. This claim is based on the following

described livestock which was sold on a commission basis for my account by

(11) ______________________________________________________________

(name of selling agency/registrant) Clause 1

(12)

Date of Sale	Number of Head	Description of Livestock	Amount
			$

Attached and made a part of this claim are copies of the account of sale and other

documents covering the livestock transaction, such as copies of checks issued and unpaid

for the livestock sold by:

(13)______________________________________________________________

(name of selling agency/registrant) Clause 1

and other documents indicating the consignment of the livestock in question to such

agency for which payment has not been made. (If full and complete documents of the transaction are not available or if these papers have become lost or destroyed, the claimant should insert a statement below of the facts in such respect:)

(14)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

None of the claimed amount has been paid, and there are no setoffs or counterclaims to

the same.

I hereby authorize the Grain Inspection, Packers and Stockyards Administration, Packers and Stockyards Program to release this proof of claim form and all of the attached supporting documents to the trustee or other interested parties to facilitate the processing of my claim.

(15) _____________________________________

(signature and title of claimant)

(16) Subscribed and sworn to before me this _____ day of ______, 20_____.

(17) _____________________________________

(18) Notary Public for the State of _____________

(19) Residing at ____________________________

My commission expires

(20) _________________________ (seal)

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 is estimated to average 30 minutes 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 2110 August 2007 Page 3 of 3