Form LPS-2 Producer Request to Retain Beef Checkoff Assessments

FORM APPROVED: OMB 0581-NEW
[Insert QSBC]

Producer Request to Retain Beef Checkoff Assessments Form
The Beef Promotion and Research Act of 1985 (Act) and the Beef Promotion and Research Order (Order) require collection of a mandatory $1-per-head beef checkoff
assessment every time cattle are sold. The Act and Order authorize qualified state beef councils to collect the $1-per-head assessment. The law requires that at least 50
cents per head of the mandatory $1-per-head checkoff assessment be forwarded to the Cattlemen’s Beef Promotion and Research Board (Board) to help fund national
beef checkoff programs, while the remaining portion can be retained by the qualified state beef council.
On June 21, 2017, the U.S. District Court for the District of Montana granted a preliminary injunction enjoining USDA from continuing to allow the Montana Beef
Council (MBC) to use the assessments that it collects under the Beef Checkoff Program to fund its advertising campaigns, unless a cattle producer provides prior
affirmative consent authorizing MBC to retain a portion of the cattle producer’s assessment for state promotion, research, and information programs authorized under
the Act. As a result of this preliminary decision, at this time, the full $1-per-head assessment collected by MBC must be remitted to the Board unless a producer
provides prior affirmative consent authorizing MBC to retain up to 50 cents of the cattle producer’s assessment for state promotion, research, and information programs.
Producers who want up to 50 cents of their federal $1-per-head assessment to remain with MBC must complete this form. The form may be completed on an annual or
monthly basis. For requests submitted annually, the form must be completed each calendar year by January 15, and returned to MBC. For the remainder of calendar
year 2017, a producer may complete the form one time by circling “year” and entering month and 2017, which will indicate that the producer consents that MBC is
authorized to retain up to 50 cents of their federal $1-per-head assessment for the remaining months in 2017. If the producer decides to complete the “Producer Request
to Retain Beef Checkoff Assessment Form” on a monthly basis, the form must be postmarked to MBC by the 15th of the month following the month the cattle were
sold.
This form may also be used by producers in any other state whose Qualified State Beef Council becomes subject to a court order similar to that issued in Montana, in
accordance with the same procedures and deadlines set out in the preceding paragraph with respect to MBC. Forms should be mailed to MBC or to another
Qualified State Beef Council, as appropriate, at its general mailing addresses for official correspondence.

PRODUCER REQUEST TO RETAIN BEEF CHECKOFF ASSESSMENTS FOR ALL CATTLE MARKETED
IN THE MONTH/YEAR (circle one) OF: ______________, 20_____

Name or Business: _________________________________________________________________________________
Address: __________________________________________________________________________________________
City: ________________________________

State: _________________

Zip Code: ________________

Phone Number: ________________________ Email: ____________________________________________________
*For monthly requests, please attach a copy of your Beef Checkoff Remittance Form or other documents
supporting payment of the beef checkoff assessment as required verification of each transaction listed below.
Name of Producer

Date of Sale

Total Number of Head
Assessed

Request to Retain Portion of Checkoff
Assessments in (STATE) ($0.50/head)

Example: John Doe

08/30/2017

20

$10.00 ($0.50 per head)

Total amount authorized to be retained by the Qualified State Beef Council
I declare under the penalties provided by law, that this
STATE
Producer Request to Retain Beef Checkoff Assessments Form
has been examined by me and, to the best of my knowledge, is true, correct and complete. I also certify that I am authorized to sign this
form.
___________________________________________
DATE

_______________________________________________________________________
RESPONDING OFFICIAL’S NAME (PRINT)

___________________________________________
TITLE (PRINT)

_______________________________________________________________________
SIGNATURE

LPS-2 (Rev. 08/17)

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________________________________________________________________________________________________________________________
Qualified State Beef Council use only

Qualified State Beef Council Approval for Processing:
Amount Retained by the Qualified State Beef Council:

$_________________________

________________________________________________
Signature

_____________________________
Date

________________________________________________________________________________________________________________________

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 OMB control number for this information collection is OMB-0581-New and will be merged into OMB-0581-0093. The
time required to complete this information collection is estimated to average 5 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.
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

LPS-2 (Rev. 08/17)

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