LPS-46-1 Soybean Report & Remittance (Alternative Form)--Amount C

REPRODUCE LOCALLY. Include form number and edition date on all reproductions

FORM APPROVED. – OMB NO. 0581-0093

ALTERNATIVE FORM: To be used by first time purchasers with computerized recordkeeping systems that cannot supply information required on primary
remittance form. Columns A, B, C, and D must be completed in detail.
UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

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

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

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

total dollars paid for assessed soybeans during the

and

reporting period.

.
(A)

(B)
STATE OF ORIGIN

(C)
NET MARKET VALUE OF ASSESSED BU.

(D)

RATE

NUMBER OF BUSHELS

X.005 =

$

PURCHASED (ALL STATES)

X.005 =

$

X.005 =

$

NET MARKET VALUE OF

X.005 =

$

ALL BUSHELS PURCHASED

X.005 =

$

BUSHELS

(ALL STATES)
$

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

TOTAL

TOTAL ASSESSMENTS =
* LATE PAYMENT =
TOTAL REMITTANCE =

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

OFFICE USE ONLY

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-46-1 (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.