P&SP 4100 Weigher's Acknowledgement & Agreement - Poultry

OMB Control No. 0580-0015

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

Weigher’s Acknowledgement and Agreement for Weighing Live Poultry

I, _____________________________________________________________________,

(1) Weigher’s Name

employed by __________________________________________________________________,

(2) Weigher’s Company Name

at ________________________________________, ________________________, as a weigher

(3) City (4) State

of live poultry loads, have read and received the Instructions for Weighing Live Poultry issued under the authority of the Packers and Stockyards Act, 1921, as amended and supplemented. I agree to fully comply with the Instructions. I am aware that it is an offense against the United States to willfully make any false entry of weight or other information on a scale ticket or other record kept by my employer.

(5) Signature Of Weigher:
(6) Signature Of Witness:	(7) Date:

The employer of the weigher must: Send one copy of the agreement to the Regional Office of the Packers and Stockyards Program, Grain Inspection, Packers and Stockyards Administration, USDA.

Retain one copy for the weigher named on this agreement.

Response is required to acknowledge receipt of Instructions for Weighing Live Poultry and to show that weigher has read and agrees to follow the instructions (9 CFR 201.108-1). Information held confidential (9 CFR 201.96).

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 information collection is estimated to average .5 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-4100 August 2007 Page 2 of 2