No Form Number Beef Monthly Report and Remittance

Beef Promotion and Research Board

OMB 0581-0093

A program designed to increase demand for beef
Information is required by (7 CFR 1260.201). Failure to report can result in a fine. Information is held in confidential (7 CFR 1260.201).
Funded by the Beef Checkoff

.
MONTHLY REPORT AND REMITTANCE FOR ALL CATTLE PURCHASED OR MARKETED IN THE MONTH OF:

______________________/___________________________
I.D. No. :

_____________________________________________________________________________________________________

Company:

_____________________________________________________________________________________________________

Address:

_____________________________________________________________________________________________________

City:

_________________________________________________ State: __________ Zip Code: _________________________

Business Phone No.: ___________________________________________________________________________________________________
This report and assessments must be remitted by the 15th day of the month following the month in which
the cattle were marketed. Late payments are subject to a 2-percent per month late payment charge.
Instructions: Please provide the following information on all cattle you or your company marketed by completing the following table:

CATTLE AND CALVES
State of Origin

Total Number of Head Marketed

Number of Heat NOT Assessed

Number of Head per State Assessed

-

=

-

=

-

=

-

=

-

=

-

=

-

=

TOTAL

TOTAL

TOTAL

Send this report and a check payable to:

X $1.00/Head

Find remittance addresses for individual states under
the “State Beef Council” tab on this Web site.

Amount Due

$

_______________________________________________________________________________________________________________________________________

I declare under the penalties provided by law, that this report has been examined by me and to the best
of my knowledge is a true, correct, and complete report. I also certify that I am authorized to sign this report.

DATE

RESPONDING OFFICIAL’S NAME (PRINT)

TITLE (PRINT)

SIGNATURE

CHECK TO ORDER FORMS

Forward original with remittance. Retain copy for your records.
(Rev. 04/17)

See reverse for burden/non-discrimination statement

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 maintain the data
needed, and completing and review 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) 7202600 (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) 6329992. 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.