PSD- 2120 Claim Form for Livestock Sold (Clause 2, 3, 4)

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
(Clause 2, 3, 4)
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 instrument checked above)

in the amount of (9)

, due and owing for livestock purchased by

(10)
(full name and address of buyer)
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OMB Control No. 0581-0308

or his own account or as a market agency buying livestock 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 purchase and other
documents covering the livestock transaction, such as copies of checks issued and other
documents indicating the sale of the livestock in question to such purchaser 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:)
(12)

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None of the claimed amounts 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 is estimated to average 1.5 hours per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection.

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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Intentionally Left Blank

Instructions to Complete
Claim Form for Livestock Sold
Clause Two, Three & Four
Form PSD 2120
When you, as a livestock seller, have not received payment for livestock sold, use this form to submit a claim
against the livestock buyer’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 Dr., 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: (515) 323-2590
FAX: (404) 562-5848
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,
IA, IL, IN, KY, MB, MI, MN,
LA, MA, MD, ME, MS, NC,
HI, ID, KS, MT, NM, NV,
MO, ND, NE, OH, ON, SD,
NJ, NL, NH, NY, PA, PR, QC,
OK, OR, SK, TX, UT, WA, WI
RI, SC, TN, VA, VT, WV
WY
If you have questions regarding completion of any portion of the bond claim form, please contact the
Regional Office that covers the state where you reside for assistance.
In most instances, the regional office of the Packers and Stockyards Division 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 line 17.
Line Subject
No.
1.
State

Instruction
Enter the state where you live.

2.

County

Enter the county where you live.

3.

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.

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Line Subject
No.
4.
Mailing Address

Instruction
Enter your complete mailing address, street, city, state and zip+4

5.

Phone/home/cell, other
contact information

Enter your home/cell phone number(s). Enter any other contact
information where you may be reached (fax number, email address)

6.

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

9.

Amount of Claim

10.

Full Name and Address of
Buyer

11.

Date of Sale, Number of
Head, Description of
Livestock, Sales Price

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 Packers and Stockyards Division that covers your state,
province, or territory.
Enter the name of the surety company who wrote the 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 buyer that purchased the
livestock. In many cases, this will be the same information as in
Item 8. However, the buyer may be a person/firm otherwise not
listed on the referenced bond. The buyer may be a packer buyer
purchasing livestock under the packer’s bond, a clearee purchasing
livestock under a clearing agency bond, or an employee or agent of a
registered firm purchasing livestock for said firm.
Using the invoice(s) provided by you, as the seller, 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.

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Line Subject
No.
12. Statement of Facts

13.

Signature and Title of
Claimant

Instruction
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.
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 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 DEPUTY
ADMINISTRATOR, AGRICULTURAL MARKETING SERVICE, FAIR TRADE PRACTICES
PROGRAM, PACKERS AND STOCKYARDS DIVISION.

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