LS-101 Pork Promotion Investment Report

Form Approved. OMB No. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MAKRETING SERVICE

PORK PROMOTION INVESTMENT REPORT

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.

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(USE LABEL PROVIDED)

ACCT.#
NAME
ADDRESS
CITY
STATE		ZIP
PHONE

CHECK IF ADDRESS CHANGED

CHECK TO ORDER FORMS

Pork Producer Checkoff Investments are shared by national and state organization to conduct pork industry promotion, research and consumer information programs.

MARKET HOG/CULL SOWS/BOARS INVESTMENT

State of Origin		Number of Hogs		Gross Market Value		Promotion Assessment
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
Total:		HD		$	Total:	$

FEEDER/ISOWEAN/PIG INVESTMENT

State of Origin		Number of Hogs		Gross Market Value		Promotion Assessment
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
Total:		HD		$	Total:	$

SEEDSTOCK INVESTMENT

State of Origin		Number of Hogs		Gross Market Value		Promotion Assessment
		HD		$	x .xxxx of Gross	$
		HD		$	x .xxxx of Gross	$
Total:		HD		$	Total:	$

DUE:

15 DAYS AFTER PERIOD ENDING DATE*

TOTAL AMOUNT OF CHECK

$

1.5% LATE CHARGE PER MONTH WILL BE BILLED

PERIOD COVERED

THRU

(month/day)

(month/day)

Monthly reporting required on assessments of $25 per month. Assessments less than $25 during each month of a quarter may be reported quarterly.

I hereby certify under penalty by law that the information contained in this Investment Report is true and accurate.

Signature

Date

Mail this form with the required information to: National Pork Board, 1776 NW 114th Street, Clive, Iowa 50325

LS-101