QSSB-1 Producer Redirection of Checkoff Assessments Form

Approval: OMB 0581-0294

Producer Redirection of Checkoff Assessments Form
The Soybean Promotion, Research, and Consumer Information Act and Order require collection of a mandatory 0.5 percent of the net market price per bushel checkoff assessment
every time soybeans are sold. The Act and Order authorize State soybean councils to retain 50 percent of the mandatory checkoff assessment (i.e., 0.25 percent of the net market
price per bushel checkoff assessment) for in-State research and promotion programs conducted by the State soybean boards. The Act requires that half of the mandatory checkoff
assessment be forwarded to the United Soybean Board (Soybean Board) to help fund national soybean checkoff programs. [State] producers may use this form to request that the
[QSSB] send the full 0.5 percent of the net market price per bushel checkoff assessment from their individual soybean sales to the Soybean Board and that the [QSSB] 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 last day of the month following the month the soybeans were sold and
mailed to the appropriate QSSB.

PRODUCER REDIRECTION OF CHECKOFF ASSESSMENTS FOR ALL SOYBEANS 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 soybean checkoff assessment
as required verification of each transaction listed below.
Name of First Purchaser that
collected the Soybean Checkoff
Assessment

Example: ABC Elevator

Date of Sale

1/15/2019

Total Number of
Bushels Assessed

Net Market Price
(NMP) of
Assessed Bushels

Requested Redirection of State Portion of
Checkoff Assessments to the Soybean Board
(0.25% of net market price per bushels sold)

1,000

$8,000 (NWP)
(i.e., 1,000 x
8.00/bu = NWP)

$20.00
(i.e., $8,000 x .0025 (0.25%) of net market
price per bushels sold)

Total amount requested for redirection to the Soybean 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
[QSSB Name] use only

[QSSB NAME] Approval for Processing:
Amount to be redirected to the Soybean Board:

Signature
QSSB-1 (Expiration Date 11/2022)

$

Date
See reverse for burden/non-discrimination statement

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