Form LPS-76 Shell egg Surveillance Quarterly Cost Rept.

FORM APPROVED - OMB 0581-0113

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
LIVESTOCK, POULTRY, AND SEED PROGRAM

SHELL EGG SURVEILLANCE QUARTERLY COST REPORT

The information is needed as a basis of payment for performing shell egg surveillance
work. Response is required to obtain payment (7 CFR 57).

INSTRUCTIONS: Prepare in four copies. Send original and two copies to reach the
applicable Federal-State Supervisor no later than the 20th of the month following the end
of the reporting quarter. Retain the last copy for your records.

2. REPORTING QUARTER (From-Thru)

1. COOPERATING AGENCY (Name and Location)

ACTUAL DIRECT COSTS
3. PERSONNEL SALARY COSTS
Travel Hours

Work Hours

Total Hours

Total Cost

a. Inspector..........................
b. Supervisor.......................
c. Clerical.............................
d. Total Personnel Salary Costs (a+b+c)......................................................
4. FRINGE BENEFITS

Explanation

e. Line d times _________________ % Percentage Rate..............................
5. TRAVEL COSTS

Explanation - Other Travel Costs

f. Total miles ______________ times $_______________¢ per mile.............
g. Lodging and meals.......................................................................................
h. Other travel costs (Explain)..........................................................................

i. Total Travel Cost (f+g+h)............................................................................
6. OTHER COSTS

Explanation

j. Telephone (Explain).......................................................................................
k. Supplies (Explain).........................................................................................
l. Miscellaneous (Explain).................................................................................
m. Total Other Costs (j+k+l)...........................................................................
7. TOTAL ACTUAL DIRECT COSTS (d+e+i+m).............................................

INDIRECT COST (If Applicable)
Calculation
8. Applicable portion of line 7 times ________% Approved Percentage Rate

9. TOTAL QUARTERLY COSTS (7+8)............................................................
10. REMARKS (continue on reverse if needed)

11. SIGNATURE OF STATE REPRESENTATIVE

14. SIGNATURE OF FEDERAL-STATE SUPERVISOR

LPS-76 (01-2015)

12. TITLE

13. DATE

15. DATE

(See reverse of Form for Privacy Act Statement)

FORM APPROVED - OMB 0581-0113

NOTE: 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 0581-0113. The time required to complete this information collection is estimated
to average1.5 hours 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.

LPS-76 (01-2015)