P&SP 1500 Live Poultry Dealer Inquiry

OMB No. 0580-0015
Expires: xx/xx/20xx

U.S. DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND
STOCKYARDS ADMINISTRATION
PACKERS AND STOCKYARDS PROGRAM

LIVE POULTRY DEALER INQUIRY
Section 1 - General Information

1. Name and Address

2. Type of Organization
‰ Association
‰ L.L.C.
‰ Corporation
‰ L.L.P.
‰ Individual
‰ Partnership
‰ Other __________________
(Specify)

3a. Telephone No.

5. State Formed:
___________________

3b. Fax No.

Date Formed:
___________________
6. If firm operates on a fiscal
year, list fiscal year:

3c. Cell Phone No.

From: ______________
4. E-mail Address
To: _________________
7a. Name and Mailing Address of Owners, Officers,
Directors, and/or Partners

7b.

7c. Title

7d. %
Ownership

Section 2 - Description Of Business
8. The poultry firm is a (check all that apply)

‰ Slaughterer
‰ Processor

‰ Broker (live)
‰ Dealer (live)

‰ Meat Dealer or Broker

Section 3 - Live Poultry Purchases
9b. FSIS Establishment No.
9a. Did the firm purchase live poultry for slaughter? ‰ Yes ‰ No
10. Did the firm purchase live poultry to sell to a firm that slaughters?
Form P&SP-1500

‰ Yes

‰ No
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11. Did the firm’s purchases originate outside the state in which it was slaughtered?

‰ Yes ‰ No

12. Total annual live poultry purchases $___________________________
Section 4 - Live Poultry Produced Under Growing Arrangements
13. Did firm obtain poultry using growing arrangements for its own slaughter?

‰ Yes

‰ No

14. Did firm sell or contract poultry obtained using a growing arrangement?

‰ Yes

‰ No

15. Did obtained poultry originate outside the state in which it was slaughtered ?

‰ Yes

‰ No

16. Number of growers with growing arrangements _____________
17. Estimated yearly value of the poultry obtained under growing arrangements annually $____________________
Section 5 - Poultry Product Sales
18. Did the firm manufacture or prepare poultry products and then sell or ship those products
outside the state of slaughter?
19. Did the firm manufacture or prepare poultry products and then sell or ship those products
to the U.S. Government?
Section 6 - Poultry Product Sold

‰ Yes

‰ No

‰ Yes

‰ No

20. Total dollar amount sales of poultry products and by-products sold on an annual basis? $_______________
Section 7 – Remarks
21. Use this space for additional information or explanation for any numbered items above, making reference to the
item number.

Section 8 - Certification

_________________________________
22. Signature

______________________________________
23. Title

________________________________
24. Date

Form P&SP-1500

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The Packers and Stockyards Act provides in part that “any person who shall willfully make, or cause to be made, any false entry or statement of
fact in any report required to be made under this Act … shall be deemed guilty of an offense against the United States, and shall be subject, upon
conviction in any court of the United States of competent jurisdiction, to a fine of not less than $1,000 nor more than $5,000, or to imprisonment
…”
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 is 0580-0015.
The time required to complete this collection is estimated to average 54 minutes per response, including the time to review instructions, search
existing data resources, gather and maintain 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) 7206382 (TDD). USDA is an equal opportunity provider and employer.

Form P&SP-1500

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