PY-210P Poultry Products Grading Certificate

(See reverse of form for OMB and EEO Statement)

FORM OMB APPROVED - NO. 0581-0127

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
POULTRY PROGRAMS

This certificate is receivable in all courts of the United States
as prima facie evidence of the truth of the statements therein
contained. This certificate does not excuse failure to comply
with any of the regulatory laws enforced by the United
States Department of Agriculture.

POULTRY PRODUCTS
GRADING CERTIFICATE

NAME AND ADDRESS OF SHIPPER OR SELLER 1/

TO: APPLICANT (Name and address, including ZIP)

LOT NO.

LOT NO.

NO.
CONTAINERS
PER LOT 1/

NO.
CONTAINERS
EXAMINED

PRODUCT
(KIND, CLASS, TYPE, STYLE, SUBSTYLE)

TYPE AND CONDITION OF CONTAINERS

CERTIFICATE NO.

PPAPLACE EXAMINED

NAME AND ADDRESS OF RECEIVER OR BUYER 1/

TEST
MARKED WEIGHT OF
• • Shortage
LOT 1/
• • Overage

WHERE HELD AND TEMPERATURE

TOTAL NET

OFFICIAL U.S.
GRADE

CONTAINERS WERE STAMPED WITH
• • Sample
• • All
• • Sample
• • All
• • Sample
• • All

ADDITIONAL CERTIFICATION

Product represented by this certificate meets specification requirements for:
_______________________________________________________________________________ ________

Check each applicable box:
• • Product derived from poultry of domestic origin.
• • The number of containers shown above was counted by the official grader.

___________________________________________________________DATED_______________ ______

CONTRACT #

DELIVERY ORDER #

NOTICE-TO-DELIVER #

• • Destination weight and temperature certification.

Test weighing performed on ____________________ at ____________________ am/pm.

REMARKS

CERTIFICATION STATEMENT
In compliance with the Regulations of the Secretary of Agriculture Governing the Grading of Poultry issued pursuant to the Agricultural Marketing Act of 1946, as amended, and any other Act of Congress
conferring like authority, it is certified that the product(s) listed hereon were examined and that the class, quality, quantity, and/ or condition of the product(s) at the time and on the date shown, were as
stated above.
__________________________________________________________________________________________________
OFFICIAL GRADER (Signature)
1/ As stated by applicant or contractor.
PY-210P (12-03) (Previous edition dated 01-99 may be used.)

_____________________________________________
DATE

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0581-0127. The time required to complete this information
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existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information.
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.

PY-210P (03-10) (REVERSE)