LPS-46 Soybean Report & Remittance--Amount Collected & Due on S

REPRODUCE LOCALLY. Include form number and edition date on all reproductions
UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

FORM APPROVED. – OMB NO. 0581-0093

Note: Information is required by 7 CFR 1220.223. Failure to report can result in
a fine. Information is held confidential (7 CFR 1220.243).

SOYBEAN PROMOTION,
RESEARCH, AND CONSUMER
INFORMATION PROGRAM
(SPARC)

A program of promotion, research, and consumer information
designed to strengthen, expand and develop new foreign and
domestic markets for soybeans and soybean products.

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.

REPORT AND REMITTANCE OF AMOUNT COLLECTED AND DUE ON SOYBEANS PURCHASED
NAME AND ADDRESS (include P.O. Box or Street, City, State, and ZIP)

Federal Identification Number
State Grain Dealer License Number (if applicable)
County
Business Telephone (include area code)

The report and assessments must be remitted (postmarked) by the last day of the
month following the end of the collection period. Late Payments are subject to a
2 percent per month late payment charge. Must be remitted by

or discounts such as moisture and quality factors) is the

.

The following report is a report on soybeans purchased and the net market value
paid for such purchases for the period commencing
ending
STATE OF
ORIGIN

total dollars paid for assessed soybeans during the

and

reporting period.

.
NUMBER OF BUSHELS
PURCHASED

NUMBER OF
BUSHELS ASSESSED

“Net market value” (quoted price plus or minus premiums

NET MARKET VALUE
OF ASSESSED
BUSHELS

RATE

TOTAL

X.005 =

$

X.005 =

$

X.005 =

$

X.005 =

$

X.005 =

$

TOTAL ASSESSMENTS =

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

* LATE PAYMENT =
TOTAL REMITTANCE =

OFFICE USE ONLY

SEND THIS REPORT AND A CHECK IN THE TOTAL AMOUNT SHOWN ABOVE TO:

PENALTIES: 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., Section 1001).

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 believe is a true, correct and complete report.

NAME/TITLE (Print or type)

LPS-46 (Rev. 04/17)

SIGNATURE

DATE

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.