LPS-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.
(USE LABEL PROVIDED)

CHECK IF ADDRESS CHANGED

ACCT.#
NAME

CHECK TO ORDER FORMS

ADDRESS
CITY
STATE

ZIP

PHONE

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

State of Origin

HD
HD
HD
HD
HD
HD
HD

Total:
State of Origin

Total:

State of Origin

Number of Hogs

Gross Market Value

$
$
$
$
$
$
$

x .0040 of Gross
x .0040 of Gross
x .0040 of Gross
x .0040 of Gross
x .0040 of Gross
x .0040 of Gross
Total:

Promotion Assessment
$
$
$
$
$
$
$

FEEDER/ISOWEAN/PIG INVESTMENT
Gross Market Value

Promotion Assessment

HD

$

x .0040 of Gross

$

HD
HD
HD
HD

$
$
$
$

x .0040 of Gross
x .0040 of Gross
x .0040 of Gross
Total:

$
$
$
$

SEEDSTOCK INVESTMENT

Number of Hogs
HD
HD
HD

Total:

DUE:

MARKET HOG/CULL SOWS/BOARS INVESTMENT

Number of Hogs

Gross Market Value
$
$
$

15 DAYS AFTER PERIOD ENDING DATE*
1.5% LATE CHARGE PER MONTH WILL BE BILLED

x .0040 of Gross
x .0040 of Gross
Total:

Promotion Assessment
$
$
$

TOTAL AMOUNT OF CHECK
PERIOD COVERED

$
THRU

(month/day)

20
(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, Street or P.O. Box, City, State Zip

LPS-101 (Rev. 04/17)

See reverse for burden/non-discrimination statement

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in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit
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