Form QSBC-1 Producer Redirection of Checkoff assessments Form

Approval: OMB 0581-0294

Producer Redirection of Checkoff Assessments Form
The Beef Promotion and Research Act and Order require collection of a mandatory $1-per-head beef checkoff assessment every time cattle are sold. The Act and Order authorize State beef councils to retain up
to 50 cents per head of the mandatory $1-per-head checkoff assessment for in-State research and promotion programs conducted by the State beef council. The law requires that at least 50 cents of the
mandatory $1-per-head checkoff assessment be forwarded to the Cattlemen’s Beef Promotion and Research Board (Beef Board) to help fund national beef checkoff programs. Producers may use this form to
request that QSBC send the full $1-per-head beef checkoff assessment from their individual cattle sales to the Beef Board and that the QSBC not retain any portion of the individual’s assessment for its direct
programing efforts.

This “Producer Redirection of Checkoff Assessment Form” must be postmarked by the 15th of the month following the month the cattle were sold and
mailed to the appropriate QSBC.

PRODUCER REDIRECTION OF CHECKOFF ASSESSMENTS FOR ALL CATTLE MARKETED
IN THE MONTH OF: ______________, 20_____
Company:

Requested by:

Address:
City:

State:

Phone Number:

Email:

Zip Code:

Please attach a copy of documents supporting payment of the beef checkoff assessment
as required verification of each transaction listed below.
Name of Collecting Point that
collected the Beef Checkoff
Assessment
Example: ABC Livestock Market

Date of Sale

Total Number of Head
Assessed

Requested Redirection of State Portion of
Checkoff Assessments to the Beef Board
($0.50/head)

1/15/2019

20

$10.00 ($0.50 per head)

Total amount requested for redirection to the Beef Board
I declare under the penalties provided by law, that this Producer Redirection of Checkoff Assessments form has been examined by me and,
to the best of my knowledge, is true, correct and complete. I also certify that I am authorized to sign this form.
______________________________________________________________________________________________________________
DATE
RESPONDING OFFICIAL’S NAME (PRINT)
______________________________________________________________________________________________________________
TITLE (PRINT)
SIGNATURE

[QSBC Name] use only

[QSBC NAME] Approval for Processing:
Amount to be redirected to the Beef Board:

Signature

QSBC-1 (Expiration Date 11/2022)

$

Date

See reverse for burden/non-discrimination statement

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 0581-0294. The time required to
complete this information collection is estimated to average 5 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.
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.