LPS-378 Sorghum--Rept. and Remittance of Amount Collected and Du

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

FORM APPROVED. – OMB NO. 0581-0093

Note: Information is required by 7 CFR 1221.116. Failure to report can result in
a fine. Information is held confidential (7 CFR 1221.127).
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 15 minutes 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

SORGHUM, PROMOTION,
RESEARCH, AND INFORMATION PROGRAM
A program of promotion, research, and consumer information
designed to strengthen the sorghum industry.

Privacy Act Notice Public Laws 95-113 and 93-579 permit collection of the data
requested on this form. The information is used to identify entities that collect
and remit assessments.

REPORT AND REMITTANCE OF AMOUNT COLLECTED AND DUE ON SORGHUM 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. The following report is a report on sorghum purchased and the net
market value paid for such purchases for the period commencing _________________and
ending__________________.
STATE OF
ORIGIN

NUMBER OF BUSHELS PURCHASED

NUMBER OF BUSHELS ASSESSED

NET MARKET VALUE OF ASSESSED BUSHELS

NUMBER OF TONS PURCHASED

NUMBER OF TONS ASSESSED

NET MARKET VALUE OF ASSESSED TONS

“Net market value” is the value found by
multiplying the net market price (the sales
price or other value, per volumetric unit,
received by a producer after adjustments for
any premium or discount) by the appropriate
quantity, bushels or tons, of sorghum. “Net
market value” may also mean the minimum
value in a production contract received by a
sorghum producer.
RATE
x.006=
x.0035=
x.006=
x.0035=
x.006=
x.0035=
x.006=
x.0035=
x.006=
x.0035=
x.006=
x.0035=

* NOTE: If remitting assessments past due date, calculate the 2 percent mandatory
late payment (compounded monthly).
Total Assessments x.02 = Late Payment
SEND THIS REPORT AND A CHECK IN THE TOTAL AMOUNT SHOWN ABOVE TO:

United Sorghum Checkoff Program
Street
City, State Zip

TOTAL
$
$
$
$
$
$
$
$
$
$
$
$

TOTAL ASSESSMENTS =
* LATE PAYMENT =
TOTAL REMITTANCE =

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-378 (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.