P&SP 2110 Proof of Claim Under Surety Bond - Clause No. 1

Instructions to Complete
Proof of Claim under Surety Bond
Clause One
Form P&SP-2110
Any person(s)/firm that sells livestock through a market agency, selling on commission (referred to as the Principal) that does not
receive payment for said livestock has the right to submit a claim against the bond of the Principal. This form may be used to
submit a claim against the Principal’s bond.
Mail two copies of the completed notarized form with accompanying documentation, to the regional office of the Packers and
Stockyards Program as listed below. The states covered by each regional office are listed below its address. A copy should be
retained in your files.
Regional Offices of the Packers and Stockyards Program
Grain Inspection, Packers and Stockyards Administration
Eastern Regional Office
Western Regional Office
Midwestern Regional Office
Suite 230
3950 Lewiston St., Suite 200
Room 317
75 Spring Street
Aurora, CO 80011-1556
210 Walnut Street
Atlanta, GA 30303-3308
Telephone: (303) 375-4240
Des Moines, IA 50309-2110
Telephone: (404) 562-5840
FAX: (303) 371-4609
Telephone: (515) 323-2579
FAX: (404) 562-5848
e-mail:
FAX: (515) 323-2590
e-mail:
[email protected]
e-mail:
[email protected]
[email protected]
States Covered
States Covered
States Covered
AL, AR, CT, DC, DE, FL, GA, LA,
AK, AZ, CA, CO, HI, ID, KS, MT,
IA, IL, IN, KY, OH, MI, MO, MN, ND,
MA, MD, ME, MS, NC, NH, NJ, NY,
NM, NV, OK, OR, TX, UT, WA, WY
NE, SD, WI
PA, RI, SC, TN, VA, VT, WV
If you have questions regarding completion of any portion of the bond claim form, please contact the Regional Office that covers
the state where you reside for assistance.
In most instances, the regional office of the Packers and Stockyards Program will complete line numbers 6, 7, 8, 10, and 11. This
is not a requirement, and the claimant may complete those items of the form.
The claimant(s) must complete line numbers 1, 2, 3, 4, 5, 9, 12, 13, and 14, and must sign line 15.
A NOTARY PUBLIC must complete line numbers 16, 18, 19 and 20, and sign Item 17.

Line
No.
1.
2.
3.
4.
5.
6.

Subject

Instruction

State
County
Full Name of Claimant

Enter the state where you live.
Enter the county where you live.
Enter your full name or your firm’s name, respectively, as the
person(s)/firm making claim against the Principal’s bond.
Enter the complete mailing address where you live.
Enter home/cell number.
If a trustee has been named on the referenced bond, enter that name as
listed on the bond on file with the Packers and Stockyards Program. If a
trustee is not required on the bond, enter “None Named,” or leave this item
blank. If you do not know the name of the trustee, or whether a trustee is
required for the referenced bond, contact the regional office of the Packers
and Stockyards Program that covers your state.

Complete Mailing Address
Phone home/cell
Name of Trustee or Surety
(if applicable)

P&SP-2110-i

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Line
No.
7a.

Subject

Instruction

Name of Surety Company

Enter the name of the surety company that wrote the bond for the Principal.
If you do not know the name of the surety, contact the regional office of the
Packers and Stockyards Program that covers your state.
Enter the name of the depository where security is held. If you do not
know the name of the depository, contact the regional office of the Packers
and Stockyards Program that covers your state.
Enter the name of the trustee where the letter of credit is held. If you do not
know the name of the trustee, contact the regional office of the Packers and
Stockyards Program that covers your state.
Enter the name of the Principal, as listed on the surety bond. Include the
Principal’s full address. The Principal is also known as the “Selling
Agency Registrant.” If you do not know the name of the Principal, contact
the regional office of the Packers and Stockyards Program that covers your
state.
Enter the amount you are claiming against the Principal’s bond. Be
reminded that you may only file your claim for the amount of livestock
sold, or other lawful charges, as allowed by 9 CFR 201.33 issued under the
Packers and Stockyards Act, 1921, as amended and supplemented.
Enter the full name and address of the selling agency where the livestock
was sold. In many cases, this will be the same information as in Item 8.
Enter the name of the selling agency that sold the livestock. This will be
the same information as Item 10.
Using the invoice(s) provided by the selling agency, enter each of the
date(s) the livestock was sold, the number of head sold, what type of
livestock was sold, and the amount the livestock was sold for.
Enter the name of the selling agency that sold the livestock. This will be
the same information as Item 10.
Attach copies of the account of sale and/or other documents covering the
livestock transaction, copies of checks issued and unpaid for the livestock,
and other instruments indicating the consignment of the livestock. If the
documents for the transaction(s) are incomplete or unavailable, enter a
statement of facts of the transaction(s) in this section.
Sign the claim form and enter your title, if applicable.

7b.

Depository

7c.

Name of Trustee

8.

Full Name and Address of
Principal Named in Bond

9.

Amount of Claim

10.

Full Name and Address of
Selling Agency Registrant
Name of Selling Agency/
Registrant
Date of Sale, Number of
Head, Description of
Livestock, Amount
Name of Selling Agency
Registrant
Statement of Facts

11.
12.

13.
14.

15.

Signature and Title of
Claimant

A Notary Public must complete Items 16, 17, 18, 19 and 20.
16.
17.
18.
19.
20.

Subscribed and Sworn
Signature
Notary Public for the State
of
Residing At
My Commission Expires

Enter the date, month, and year the Notary signed the claim form.
The Notary must sign line number 17.
Enter the state where the Notary is licensed.
Enter the city where the Notary lives.
Enter the date the Notary’s commission expires.

THIS CLAIM MUST BE NOTARIZED BEFORE SUBMITTING TO THE DEPUTY
ADMINISTRATOR, PACKERS AND STOCKYARDS PROGRAMS.

P&SP-2110-i

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OMB CONTROL NO. 0580-0015
Expires: xx/xx/20xx

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

Proof of Claim Under:
1. Surety Bond, (Clause 1)
2. Trust Fund Agreement, (Clause 1)
3. Trust Agreement, (Clause 1)
Issued Under Provisions of The Packers and
Stockyards Act, 1921, as Amended and Supplemented

State of (1) ________________________________________
County (2) ________________________________________
As the undersigned, I, (3) ___________________________________________________
(full name of claimant)
Of (4) __________________________________ (5) _____________________________
(phone: home, cell)
(complete mailing address)
________________________________________________________________________
(other contact information: fax number, email address)
being duly sworn, depose and state:
I make this claim to (6) ____________________________________________________
(name of trustee or surety)
Select One:
… under the bond issued by the (7a)
___________________________________________________________
(name of surety company)
… under the Trust Fund Agreement with security held by (7b)
____________________________________________________________
(depository, if one named)
… under the Trust Agreement with letter of credit held by (7c)
____________________________________________________________
(name of trustee)

on behalf of (8) ___________________________________________________________
(full name and address of principle named in the instrument checked above)
________________________________________________________________________
in the amount of (9) _____________, which is the proceeds from livestock sold by
(10) ______________________________________________________
(full name and address of selling agency/registrant) Clause 1
for my account on a commission basis. This claim is based on the following

Form P&SP 2110

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OMB CONTROL NO. 0580-0015

described livestock which was sold on a commission basis for my account by
(11) ______________________________________________________________
(name of selling agency/registrant) Clause 1

(12)
Date of Sale

Number of Head

Description of Livestock

$

Amount

Attached and made a part of this claim are copies of the account of sale and other
documents covering the livestock transaction, such as copies of checks issued and unpaid
for the livestock sold by:
(13)______________________________________________________________
(name of selling agency/registrant) Clause 1

and other documents indicating the consignment of the livestock in question to such
agency for which payment has not been made. (If full and complete documents of the transaction
are not available or if these papers have become lost or destroyed, the claimant should insert a statement
below of the facts in such respect:)

(14)____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Form P&SP 2110

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OMB CONTROL NO. 0580-0015

None of the claimed amount has been paid, and there are no setoffs or counterclaims to
the same.
I hereby authorize the Grain Inspection, Packers and Stockyards Administration, Packers
and Stockyards Program to release this proof of claim form and all of the attached
supporting documents to the trustee or other interested parties to facilitate the processing
of my claim.

(15) _____________________________________
(signature and title of claimant)
(16) Subscribed and sworn to before me this _____ day of ______, 20_____.
(17) _____________________________________
(18) Notary Public for the State of _____________
(19) Residing at ____________________________
My commission expires
(20) _________________________ (seal)

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 0580-0015. The time
required to complete this information collection is estimated to average 1 hour 30 minutes per response, including the time for reviewing instructions, searching
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.

Form P&SP 2110

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