LPS-81 Lamb- Monthly Remittance Report

FORM APPROVED - OMB NO. 0581-0093

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

LAMB PROMOTION, RESEARCH, AND INFORMATION BOARD REMITTANCE REPORT
Information is required by 7CFR §1280.223. Failure to report can result in a fine. Information provided in this report is held confidential under 7CFR §1280.227.
Note: 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 SHEEP AND LAMBS

FOR THE PURPOSE OF THIS PROGRAM: A Lamb is defined as an ovine animal of any age, including ewes and rams.
NAME AND ADDRESS (Include street address or P.O. Box No., City, State, Zip Code)

CHECK THE APPROPRIATE TRANSACTION(S):
Live sheep or lambs purchased for slaughter
Exported sheep or lambs
Custom slaughter or direct marketing of sheep or lambs

Business Telephone Number (include area code): (
ASSESSMENTS ON LIVE SHEEP OR LAMBS REMITTED DURING THE MONTH OF

)

-

, 20_____

The report and assessments must be remitted (postmarked) by the 15th day of the month following the end of the collection period. Late Payments are subject to a 2% per
month late payment charge.

NUMBER OF SHEEP OR LAMBS ASSESSED

TOTAL POUNDS OF LIVE SHEEP OR LAMBS

ASSESSMENT RATE PER POUND

TOTAL

x $.007
x $.007
x $.007
x $.007

x $.007

TOTAL SHEEP OR LAMBS SLAUGHTERED
(first handler fee, rate of $0.42 per head):

x $.42

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

TOTAL ASSESSMENTS=
*LATE PAYMENT=
TOTAL REMITTANCE=

If the assessment is less than the total pounds of live weight sold, explain:

Send this report and a check for the total remittance to:
American Lamb Board
Street
City, State Zip

CERTIFICATION STATEMENT

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.
§1001).

I declare under the penalties provided by law, that this report has been examined by me and to the best of my knowledge and belief is a true, correct and

complete report. I also certify that I am authorized to sign this report.
RESPONDING OFFICIAL'S NAME AND TITLE (Print)

LPS-81 (Rev. 04/17) (Destroy previous editions)

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.