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

OMB CONTROL NO. 0581-0308

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)

Form PSD 2110

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OMB CONTROL NO. 0581-0308

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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OMB CONTROL NO. 0581-0308

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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OMB CONTROL NO. 0581-0308

Intentionally Left Blank

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OMB CONTROL NO. 0581-0308

Instructions to Complete
Claim Form for Livestock
Sold on Commission
Clause One
Form PSD 2110
Any person(s)/firm that sells livestock through a market agency, selling on commission (referred to as the
Principal) that does not receive payment for said livestock has the right to submit a claim against the
financial instrument of the Principal. This form may be used to submit a claim against the Principal’s
financial instrument.
Submit two copies of the completed notarized form with accompanying documentation, to the regional office
of the Packers and Stockyards Division (PSD) as listed below. The states, provinces, and territories covered
by each regional office are listed below its address. A copy should be retained for the complainant’s files.
Regional Offices of the Packers and Stockyards Division
Agricultural Marketing Service, Fair Trade Practices Program
Atlanta Regional Office
Denver Regional Office
Des Moines Regional Office
75 Ted Turner Drive, SW, Ste 230 3950 Lewiston St., Suite 200
210 Walnut Street, Room 317
Atlanta, GA 30303-3308
Des Moines, IA 50309-2110
Aurora, CO 80011-1556
Telephone: (404) 562-5840
Telephone: (303) 375-4240
Telephone: (515) 323-2579
FAX: (404) 562-5848
FAX: (515) 323-2590
FAX: (303) 371-4609
e-mail:
e-mail:
e-mail:
[email protected]
[email protected]
[email protected]
States Covered
States Covered
States Covered
AL, AR, CT, DC, DE, FL, GA,
AB, AK, AZ, BC, CA, CO, HI, IA, IL, IN, KY, MB, MI, MN,
LA, MA, MD, ME, MS, NC, NJ,
ID, KS, MT, NM, NV, OK, OR, MO, ND, NE, OH, ON, SD,
NL, NH, NY, PA, PR, QC, RI, SC, SK, TX, UT, WA, WY
WI
TN, VA, VT, WV
If you have questions regarding completion of any portion of the claim form, please contact the Regional
Office that covers the state where you reside for assistance.
In most instances, the regional office of the PSD will complete line numbers 6, 7, 8, 10, and 11. This is not a
requirement, and the claimant may complete those items of the form, if known.
The claimant(s) must complete line numbers 1, 2, 3, 4, 5, 9, 12, 13, and 14, and must sign line 15.
A NOTARY PUBLIC must complete line numbers 16, 18, 19 and 20, and sign Item 17.
Line
No.
1.
2.

Subject

Instruction

State
County

Enter the state where you live.
Enter the county where you live.

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OMB CONTROL NO. 0581-0308

Line
No.
3.
4.
5.
6.

Subject

Instruction

Full Name of Claimant

Enter your full name or your firm’s name, respectively, as the
person(s)/firm making claim against the Principal’s bond or financial
instrument.
Enter your complete mailing address, street, city, state, and zip+4.
Enter your home/cell phone number(s). Enter any other contact
information where you may be reached (fax, email address)
If a trustee is named on the referenced bond or financial instrument
(document), enter that name as listed on the document on file with
the PSD. If a trustee is not required on the document, enter “None
Named,” or leave this item blank. If you do not know the name of
the trustee, or whether a trustee is required, contact the regional
office of the PSD that covers your state, province, or territory.
Enter the name of the surety company who wrote the surety bond for
the Principal. If you do not know the name of the surety, contact the
regional office of the PSD which covers your state, province, or
territory.
Enter the name of the trustee. If you do not know the name of the
trustee, contact the regional office of the PSD that covers your state,
province, or territory.
Enter the name of the trustee. If you do not know the name of the
trustee, contact the regional office of the PSD that covers your state,
province, or territory.
Enter the name of the Principal, as listed on the financial instrument.
Include the Principal’s full address. If you do not know the name of
the Principal, contact the regional office of the PSD that covers your
state, province or territory.
Enter the amount you are claiming against the Principal’s financial
instrument. Be reminded that you may only file your claim for the
amount of livestock sold, or other lawful charges, as allowed by
9 C.F.R. 201.33 issued under the Packers and Stockyards Act, 1921,
as amended and supplemented.
Enter the full name and address of the selling agency where the
livestock was sold. In many cases, this will be the same information
as in Item 8.
Using the invoice(s) provided by the selling agency, enter each of the
date(s) the livestock was sold, the number of head sold, what type of
livestock was sold, and the amount the livestock was sold for.
NOTE: Attach copies of the account of sale and/or other documents
covering the livestock transaction, copies of checks issued and
unpaid for the livestock, and other instruments indicating the
consignment of the livestock. If the documents for the transaction(s)
are incomplete or unavailable, enter a statement of facts of the
transaction(s) in this section.

Mailing Address
Phone/home/cell, other
contact information
Name of Surety or
Trustee,
(if applicable)

7a.

Name of Surety Company

7b.

Name of Trustee - TFA

7c.

Name of Trustee - TA

8.

Full Name and Address of
Principal Named in
Financial Instrument

9.

Amount of Claim

10.

Full Name and Address of
Selling Agency/Registrant

11.

Date of Sale, Number of
Head, Description of
Livestock, Amount
Statement of Facts

12.

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OMB CONTROL NO. 0581-0308

Line
No.
13.

Subject

Instruction

Signature and Title of
Claimant

Sign the claim form and enter your title, if applicable, in the presence
of a notary public.

A Notary Public must complete Items 16, 17, 18, 19 and 20.
14.
15.
16.
17.
18.

Subscribed and Sworn
Signature
Notary Public for the State
of
Residing at
My Commission expires

Enter the date, month, and year the Notary signed the claim form.
The Notary must sign line number 17.
Enter the state where the Notary is licensed.
Enter the city where the Notary lives.
Enter the date the Notary’s commission expires.

THIS CLAIM MUST BE NOTARIZED BEFORE SUBMITTING TO THE DEPUTY
ADMINISTRATOR, AGRICULTURAL MARKETING SERVICE, FAIR TRADE PRACTICES
PROGRAM, PACKERS AND STOCKYARDS DIVISION.

Form PSD 2110

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