PSD- 2110 Claim--Livestock Sold on Commission (Clause 1)

U.S. Department Of Agriculture
Agricultural Marketing Service
Fair Trade Practices Program
Packers and Stockyards Division

Claim Form for Livestock Sold on Commission
(Clause 1)
Issued Under Provisions of The Packers and
Stockyards Act, 1921, as Amended and
Supplemented

State of (1)
County (2)
As the undersigned, I, (3)
(full name of claimant)
Of (4)
(Street, City, State, and Zip+4)
(5)
(phone: home, cell)
(other contact information: fax number, email address)
being duly sworn, depose and state:
I make this claim to (6)
(name of surety or trustee, if applicable)
Select One:
under the bond issued by (7a)
(name of surety company)
under the Trust Fund Agreement held by (7b)
(name of trustee)
under the Trust Agreement held by (7c)
(name of trustee)

on behalf of (8)
(full name and address of principal named in the instrument checked above)

in the amount of (9)

, which is the proceeds from livestock sold by

(10)
(full name and address of selling agency/registrant)

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for my account on a commission basis.
(11)
Date of Sale

Number of Head

Description of Livestock

Amount
$

Attached and made a part of this claim are copies of the account of sale and other
documents covering the livestock transaction, such as copies of checks issued and other
documents indicating the consignment of the livestock in question to such agency for
which payment has not been made. (If full and complete documents of the transaction are not
available or if these documents have become lost or destroyed, the claimant should insert a statement
below of the facts in such respect:)

(12)

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None of the claimed amount has been paid, and there are no setoffs or counterclaims to
the same.
I hereby authorize the Agricultural Marketing Service, Fair Trade Practices Program,
Packers and Stockyards Division to release this proof of claim form and all of the attached
supporting documents to the trustee or other interested parties to facilitate the processing
of my claim.
(13)
(signature and title of claimant)
(14) Subscribed and sworn to before me this day ______ of

, 20____.

(15)
(signature of notary)

(16) Notary Public for the State of: __________________________
(17) Residing at:

My commission expires:
(18)

(seal)

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 is 0581-0308
The time required to complete this collection is estimated to average 1.5 hours 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.

In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is
prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights
activity. (Not all prohibited bases apply to all programs.) 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 State or local
Agency that administers the program 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 is also available in languages other than English.
To file a complaint alleging discrimination, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or 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: (a) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence
Avenue, SW, Washington, D.C. 20250-9410; (b) fax: (202) 690-7442; or (c) email: [email protected]

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