P&SP 5000 Reparation Complaint

OMB CONTROL NO. 0580-0015

U.S. Department of Agriculture Grain Inspection, Packers and Stockyards Administration Packers and Stockyards Program	Reparation Complaint Before the Secretary of Agriculture
This form may be used to file complaint for reparation within 90 days after cause of action accrued in accordance with Section 309(a) of the Packers and Stockyards Act, 1921, as amended and supplemented (7 U.S.C. 210(a)).

1. Name(s) and Address(s) of Complainant(s)

v.

2. Name(s) and Address(s) of Respondent(s)

The following complaint is filed pursuant to section 309(a) of the Packers and Stockyards Act, 1921, as amended and supplemented. (7 U.S.C. 210(a)).

3. Date of Transaction: __________________ 4. Amount Claimed: $__________________

5. Name of Business and Address where transaction occurred:

6. Briefly describe the transaction involved, including the terms of the contract(s) or agreement(s) and the alleged violation(s). Attach all supporting documents and evidence.

7. Itemize and explain how you calculated amount claimed.

8. Date: _______________ 9. Signature(s) of Complainant(s): _____________________________

If space is insufficient, continue on separate paper and attach.

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-5000 August 2007 Page 2 of 2