P&SP 7003 Special Report For Review of Dealer, Market Agency and P

For P&SP Use Only

P&SP Bar Code Only

U.S. Department of Agriculture

SPECIAL REPORT FOR REVIEW OF DEALER, MARKET AGENCY AND PACKER BONDS

Grain Inspection,

Packers and Stockyards

Administration

Packers and

Instructions: If an item's value is zero, enter "0". If an item does not apply, enter "NA". Upon completion please verify that all items have been answered. Return completed form to the appropriate P&SP regional office. See separate instructions for complete information about this report.

Stockyards

Program

GENERAL INFORMATION - SECTION 1

101

Reporting Period (mm/dd/yy)

a. from

b. to

102

Legal Business Name

103

Business Name (dba)

104

Mailing Address

105

City, State, Zip

106

Telephone Number

107

Fax Number

108

Contact Name

109

Contact Number

BOND INFORMATION - SECTION 2

Livestock Sold by a Market Agency:

201

Number of Public Sale Days that were held during this reporting period:

202

Gross Value of all Livestock Sold on Commission:

$

Livestock Purchased as a Dealer for their own account and on Commission for the accounts of others:

203

Total Cost of Livestock Purchased on a Dealer Basis for Registrant's Account - Include Clearees if Applicable:

$

204

Total Cost of Livestock Purchased for the Accounts of Others - Include clearees if Applicable:

$

205

Total Cost of Livestock Purchased:

$

Livestock Purchased as a Packer:

206

Total Cost of Livestock Purchased for Feeding:

$

207

Total Cost of Livestock Purchased for Slaughter:

$

208

Total Livestock Purchased:

$

CERTIFICATION - SECTION 3

Under the Packers and Stockyards Act any person who willfully makes, or causes any false entry or statement of fact in this report shall be deemed guilty of offense against the United States, and be subject to a fine of $1,000 to $5,000, or to imprisonment for a term of not more than 3 years, or to both fine and imprisonment.

I certify that this report has been prepared by me or under my direction, and to the best of my knowledge and belief correctly reflects reporting entity operations.

701 Print Name

702 Signature (Must be signed by a person listed on 201-205)

703 Phone Number

704 Date

705 Title

Submitted information is confidential (9 CFR 201.96). Failure to report will result in forfeiture to the United States $110 per day until report receipt 7 (U.S.C. 222). This is a special report to determine adequacy of bond requirements under the Packers and Stockyards Act. 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 1/2 hour 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.