No Form Number Certification of Producer Directed Payment of Cattle Ass

OMB 0581-0093

BEEF PROMOTION AND RESEARCH BOARD

CERTIFICATION OF PRODUCER DIRECTED PAYMENT OF CATTLE ASSESSMENTS
FAILURE TO PAY THE BEEF CHECKOFF IS A VIOLATION OF FEDERAL LAW (7 U.S.C. 2901 et seq.). This
form must be properly completed and signed to be valid. You may by law be fined up to $10.000, imprisoned up to
5 years, or both for knowingly or willfully making false statements within this document (18 U.S.C. p 1001).
Date:

Producer's Name ___________________________________________

SSN or TIN

Address

State

City

Zip

Destination Facility
Address

City

I am electing to direct payment of and remit assessments in the amount of $

State ________
to the Qualified State Beef

Council (QSBC) of

, my state of residence, on
head of cattle that I have produced and am
State
Head
transporting under retained ownership on
to a feedyard or similar location in the state of
Date
State

.

I certify that these cattle are of my own production; I am transporting these cattle under retained ownership in compliance with
7 C.F.R. §1260.311 to a feedyard or similar location in another state; and these cattle shall remain in the feedyard or similar location
for a period of not less than 30 days.
I further certify that, upon remitting the producer directed assessment on these cattle, I shall send a copy of this certification form to
my QSBC. I understand that a copy of this "Certification of Producer Directed Payment of Cattle Assessments" must be provided to
the purchaser (collecting person) at the time of sale to document that the $1-per-head assessment has been paid or I will be
required to pay the assessment again.

Signature of Owner (Producer)
Composite groups of cattle (use if cattle are divided): These cattle were divided into separate groups and sold as follows:
Buyer/ Date Sold/ Head

Buyer/ Date Sold/ Head

Buyer/ Date Sold/ Head

Buyer/ Dale Sold/ Head

Buyer/ Date Sold/ Head

Buyer/ Date Sold/ Head

Buyer/ Date Sold/ Head

Buyer/ Date Sold/ Head

Signature of Feeder

Collection of your social security number is authorized by Executive Order 9397 and will be used only for the purpose
of positive identification. Furnishing this information is voluntary.

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
12 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.

FORWARD WHITE COPY WITH REMITTANCE.
RETAIN GOLD COPY FOR YOUR FILES.

SEND YELLOW COPY WITH CATTLE.
PINK COPY FOR FEEDERS FILES.

LPS (Rev. 04/17)

See reverse for burden/non-discrimination statement

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies,
offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color,
national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status,
income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity
conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign
Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the
Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the
information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW., Washington, D.C.
20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

CERTIFICATION OF PRODUCER DIRECTED PAYMENT OF CATTLE ASSESSMENTS
This is a voluntary program allowing any producer who is retaining ownership and shipping cattle of his
own production out of state for feeding, finishing, backgrounding, or grazing to elect to prepay the
checkoff assessment to the state beef council in his state of residence.
Copies made on a copier are ONLY allowed when a FEEDER divides a producer's cattle into other
groups upon leaving the feeder.
□ For the Producer:
1. Cattle of a producer's own production shall be those cattle which meet ALL of the
following requirements: a) the cattle shall be the offspring of a producer's own cowherd; b) the
cattle shall have been continuously and exclusively under the producer's ownership; and
c) the cattle are transported to a feedlot or other facility with such owner continuously owning the
cattle through the entire feeding phase.
2. If a percentage interest in the cattle is transferred while in the feedlot or other facility, the full
assessment is due when sold to the packer or other buyer. There is no refund for death loss.
3. The producer must submit the original form (white copy) and payment of the assessment to the
state beef council in his state of residence AT THE TIME or BEFORE cattle are shipped.
4. Ensure forms accompany the cattle. The dollar or document rule shall apply. If there is no
document presented at the time they are sold out of the feedlot the assessment will be collected.
5. A separate original form must be filled out by the producer for cattle going to different locations
within a state, i.e. different feedyards, even if owned by the same company. One form may be
used for multiple loads of cattle going to the same location on the same day.
□ For the Feeder:
Forms must accompany cattle upon arrival. Late forms or copies are not to be accepted.
1. If the cattle are sold as an intact group, the yellow form will go with the cattle to the packer or other
ultimate buyer. If the cattle are split up and sold with different lots or as separate units, the feeder
shall enter the groups in the spaces provided on the pink form and make enough copies to send a
copy with each group. The copy shall indicate only the prepaid cattle in the group.
2. The feeder is the only one allowed to make and use copies of the form as long as the number of
copies does not exceed the number of groups of cattle and the number of cattle in the groups
does not exceed the total on the original prepayment form.
3. The feeder will report prepaid cattle on your monthly remittance form to the state beef council. List
them as a separate category of non-assessed cattle by number of head and form number(s) on
the prepay form or make copies and send in with your monthly report. The feeder will retain the
pink copy of the original in his records for 3 years.
□ For the Packer or Ultimate Purchaser:
1. The packer or ultimate purchaser must collect the beef checkoff assessment unless the original or
approved copy of the numbered prepayment form accompanies the cattle. Report prepaid cattle
on your monthly remittance form to the state beef council as a separate category of nonassessed cattle by number of head and form number(s) on the prepay form or make copies and
send in with your monthly report. Retain the yellow form for your records.