No Form Number Beef Monthly Report and Remittance

MONTHLY REPORT AND REMITTANCE TO THE

BEEF PROMOTION AND RESEARCH PROGRAM
Information is required by (7 CFR 1260.201). Failure to report can result in a FINE. Information is held confidential (7CFR 1260.203).

Livestock Mkt.

Name/Firm:__________________________
Address:____________________________
City:___________ State:_____ Zip:_______
Phone # (___)________________________
Fax# (___)___________________________

DO NOT WRITE IN THIS BOX

Packer
Dealer

Date Rec’d _____________

Feedlot

Rec’d Initial _____________

Dairy

Check Enc.

Other

Chk#__________________

Email_______________________________

Change of Address

Transaction Month:__________, 20_____

Need more forms

Cash

Amt.___________________

Instructions: Please provide information on all cattle you or your company marketed by completing the following table.
Column A

Column B

Column C

State of Origin

Total Head
of Cattle
Marketed

Non Producer
Status Form
(Dealer/Order
Buyer)

Column D

Brand
Inspector
Collected

Column E

Livestock
Market
Collected

Column F

No Sale
Cattle

Column G

Column H

Market Support
Cattle/
Resale Cattle

Total Head NOT
Collected On

Total Head Per State
Collected On

(Sum of Columns C
through G)

(Column B minus Column H)

Total Column H

Total Column I

Total Column B

Share further explanations here:

Column I

Total Head Collected On __________X $1.00______________

This report and assessments must be remitted by the fifteenth day of the month following the month in which the cattle were
marketed. Late payments are subject to a 2% per month late payment charge.
I declare under the penalties provided by law, that this report has been examined by me and to the best of my knowledge
and belief is a true, correct and complete report. I also certify that I am authorized to sign this report.

________________________________________________________________________________
RESPONDING OFFICIAL’S NAME (Print)

DATE

Please send this form and
a check to:
Cattlemen’s Beef Promotion
and Research Board
P.O. Box 803834
Kansas City, MO 64180-3834

____________________________________________________________________________________________________
TITLE (Print)
SIGNATURE
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 0581-0093. The time required to complete this information collection is estimated to average 1 hour 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. Dept. 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.

Forward Original with Remittance. Retain Yellow Copy for Your Records.