LS-81 Monthly Remittance Report

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.

FORM APPROVED - OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

LAMB PROMOTION, RESEARCH AND INFORMATION BOARD REMITTANCE REPORT
Information is required by 7CFR § 1280.223. Failure to report can result in a fine. Information provided in this report is held confidential under 7CFR § 1280.227.
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 0581-0093. 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. 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.

REPORT AND REMITTANCE OF AMOUNT COLLECTED AND DUE ON SHEEP AND LAMBS
FOR THE PURPOSE OF THIS PROGRAM: A Lamb is defined as an ovine animal of any age, including ewes and rams.
NAME AND ADDRESS (Include street address or P.O. Box No., City, State, Zip Code)

CHECK THE APPROPRIATE TRANSACTION(S):
Live sheep or lambs purchased for slaughter
Exported sheep or lambs
Custom slaughter or direct marketing of sheep or lambs

Business Telephone Number (include area code): (

) ______-____________

ASSESSMENTS ON LIVE SHEEP OR LAMBS REMITTED DURING THE MONTH OF _________________, 20__
The report and assessments must be remitted (postmarked) by the 15th day of the month following the end of the collection period. Late Payments are subject to a 2% per
month late payment charge.

NUMBER OF SHEEP OR LAMBS ASSESSED TOTAL POUNDS OF LIVE SHEEP OR LAMBS

ASSESSMENT RATE PER POUND

TOTAL

x $.007
x $.007
x $.007
x $.007
x $.007
TOTAL SHEEP OR LAMBS SLAUGHTERED
(first handler fee, rate of $0.42 per head):

x $.42

*NOTE: If remitting assessments past due date, calculate the 2% mandatory late
payment (compounded monthly).
Total Assessments x .02 = Late Payment

TOTAL ASSESSMENTS=
*LATE PAYMENT=
TOTAL REMITTANCE=

If the assessment is less than the total pounds of live weight sold, explain:

Send this report and a check for the total remittance to:

PENALTIES: You may, by law be fined up to $10,000,
imprisoned up to five years or both for knowingly or willfully
making false statements within this document.
(18 U.S.C. § 1001).

American Lamb Board
23029 Network Place
Chicago, IL 60673-1230

CERTIFICATION STATEMENT
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 AND TITLE (Print)

LS-81 (05-13) (Destroy previous editions)

SIGNATURE

DATE