LPS-378 Sorghum--Rept. and Remittance of Amount Collected and Du

OMB No. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SORGHUM, PROMOTION, RESEARCH, AND INFORMATION PROGRAM

A program of promotion, research, and consumer information designed to strengthen the sorghum industry.

NAME AND ADDRESS (include P.O. Box or Street, City, State, and ZIP)

Note: Information is required by 7 CFR 1221.116. Failure to report can result in a fine. Information is held confidential (7 CFR 1221.127).

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 15 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.

Privacy Act Notice Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to identify entities that collect and remit assessments.

REPORT AND REMITTANCE OF AMOUNT COLLECTED AND DUE ON SORGHUM PURCHASED

County				Business Telephone (include area code)
The report and assessments must be remitted (postmarked) by the last day of the month following the end of the collection period. Late Payments are subject to a 2 percent per month late payment charge. The following report is a report on sorghum purchased and the net market value paid for such purchases for the period commencing and ending .					"Net market value" is the value found by multiplying the net market price (the sales price or other value, per volumetric unit received by a producer after adjustments for any premium or discount) by the appropriate quantity, bushels or tons, of sorghum. "Net market value" may also mean the minimum value in a production contract received by a sorghum producer.
GRAIN (Bushels)
STATE OF ORIGIN	NUMBER OF BUSHELS PURCHASED	NUMBER OF BUSHELS ASSESSED	NET MARKET VALUE OF ASSESSED BUSHELS		RATE	TOTAL
					x .006	$
					x .006	$
					x .006	$
					x .006	$
FORAGE (Tons)
STATE OF ORIGIN	NUMBER OF TONS PURCHASED	NUMBER OF TONS ASSESSED	NET MARKET VALUE OF ASSESSED TONS		RATE	TOTAL
					x .0035	$
					x .0035	$
*NOTE: If remitting assessments past the due date, calculate the 2 percent mandatory late payment (compounded monthly). Total Assessments x .02 = Late Payment					TOTAL ASSESSMENTS=
					*LATE PAYMENT=
					TOTAL REMITTANCE =
SEND THIS REPORT AND A CHECK IN THE TOTAL AMOUNT SHOWN ABOVE TO: United Sorghum Checkoff Program Address County, State, Zip XXX-XXX-XXXX					OFFICE USE ONLY
					PENALTIES: You may, by law, be fined up to $10,000, imprisoned up to 5 years, or both for knowingly or willfully making false statements within this document. (18 U.S.C. §1001).
CERTIFICATION STATEMENT

I declare, under the penalties provided by law, that this report has been examined by me; and to the best of my knowledge and belief is a true, correct and complete report.

NAME/TITLE (Print or type)

SIGNATURE

DATE

LP-378 (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.