P&SP 4100 Weigher's Acknowledgement & Agreement - Weighing Live Po

Instructions to Complete
Weigher’s Acknowledgement and Agreement
for Weighing Live Poultry or Feed
Form P&SP-4100
Mail the completed form to the appropriate regional office of the Packers and Stockyards Program as listed
below. The states covered by each regional office are listed below its address.
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,
MA, MD, ME, MS, NC, NH, NJ,
NM, NV, OK, OR, TX, UT, WA,
ND, NE, SD, WI
NY, PA, RI, SC, TN, VA, VT, WV
WY
If you have any questions regarding this form, please contact the appropriate regional office of the Packers and
Stockyards Program listed above.
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P&SP-4100-i

Subject
Name
Employer
City
State
Weigher Signature
Witness Signature
Date

Instruction
Enter name of person signing Weigher’s Acknowledgement and
Agreement.
Enter name of company weigher is employed by.
Enter city where weigher will be weighing poultry.
Enter state where weigher will be weighing poultry.
The weigher must sign the form in front of a witness.
A witness must sign the form after witnessing the weigher’s signature.
Enter date that Weigher’s Acknowledgement and Agreement was signed
and witnessed.

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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

WEIGHER’S ACKNOWLEDGEMENT
AND AGREEMENT
FOR WEIGHING LIVE POULTRY

I, _____________________________________________________________________,
(1) Weigher’s Name
employed by __________________________________________________________________,
(2) Weigher’s Company Name
at ________________________________________, ________________________, as a weigher
(3) City
(4) State
of live poultry loads, have read and received the Instructions for Weighing Live Poultry issued
under the authority of the Packers and Stockyards Act, 1921, as amended and supplemented. I
agree to fully comply with the Instructions. I am aware that it is an offense against the United
States to willfully make any false entry of weight or other information on a scale ticket or other
record kept by my employer.
(5) SIGNATURE OF WEIGHER:

(6) SIGNATURE OF WITNESS:

(7) DATE:

The employer of the weigher must: Send one copy of the agreement to the Regional Office of
the Packers and Stockyards Program, Grain Inspection,
Packers and Stockyards Administration, USDA.
Retain one copy for the weigher named on this agreement.
Response is required to acknowledge receipt of Instructions for Weighing Live Poultry and to show that weigher has read and agrees to follow
the instructions (9 CFR 201.108-1). Information held confidential (9 CFR 201.96).
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 14 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.
Form P&SP-4100
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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-4100

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