LP-101 Pork Promotion Investment Report

U.S. DEPARTMENT OF AGRICULTURE

_{AGRICULTURAL MAKRETING SERVICE}

OMB No. 0581-0093

PORK PROMOTION INVESTMENT REPORT

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 0581-0093. The time required to complete this information collection is estimated to average 1 hour 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.

_{(USE LABEL PROVIDED)}

ACCT.# NAME ADDRESS CITY

STATE ZIP

_PHONE

EMAIL ADDRESS

CHECK IF ADDRESS CHANGED CHECK TO ORDER FORMS

REQUEST ON-LINE REGISTRATION

CODE _______

_{Pork Producer Checkoff Investments are shared by national and State organization to conduct pork industry promotion, research, and consumer information programs.}

_{MARKET HOG/CULL SOWS/BOARS INVESTMENT}

State of Origin Number of Hogs Gross Market Value Promotion Assessment

		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
Total:		HD		$ Total:		$

_{FEEDER/ISOWEAN/PIG INVESTMENT}

State of Origin Number of Hogs Gross Market Value Promotion Assessment

		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
		HD		$ x .0040 of Gross		$
Total:		HD		$ Total:		$

SEEDSTOCK INVESTMENT

_{State of Origin Number of Hogs Gross Market Value Promotion Assessment}

HD	$	x .0040 of Gross	$
HD	$	x .0040 of Gross	$
HD	$	Total:	$

_Total:

DUE: ^{15 DAYS AFTER PERIOD ENDING DATE*} TOTAL AMOUNT OF CHECK $

_{1.5% LATE CHARGE PER MONTH WILL BE BILLED}

PERIOD COVERED THRU 20

(month/day) (month/day)

Monthly reporting required on assessments of $25 per month. Assessments less than $25 during each month of a quarter may be reported quarterly.

I hereby certify under penalty by law that the information contained in this Investment Report is true and accurate.

Signature Date

Now pay checkoff on-line by going to pork.org/pay or mail this form with the required information to: National Pork Board, Street or P.O. Box, City, State, and Zip

LP-101 (Expiration Date XX/XX/XXXX) See reverse for burden/non-discrimination statement

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.

LP-101 (Expiration Date XX/XX/XXXX)