LP-2 Producer Consent to Fund Form

OMB No. 0581-0093

Producer Consent to Fund [INSERT NAME OF STATE BEEF COUCNIL] Form

For All Cattle Marketed During the ___________ Calendar Year (Write in the year for which this form is being completed).

Name(s): _________________________________________ Business: _______________________________________

Address: __________________________________________________________________________________________

City: ________________________________ State: _________________ Zip Code: ________________

Phone Number: ________________________ Email: ____________________________________________________

I hereby authorize the [Insert name state beef council] to retain up to 50 cents per head of the Federal $1-per-head beef checkoff assessment collected on cattle that I sell. Assessments will be retained on all cattle marketed during the calendar year indicated above (if the form is received by the beef council by January 1, the State beef council will be authorized to retain up to 50 cents of the Federal $1-per-head assessment during the entire calendar year.  If it is received by the State beef council after January 1, the State beef council will be authorized to retain up to 50 cents of the Federal $1-per-head assessment for the remaining days of the year, beginning on the date the form was received by the State beef council). I also certify that I am authorized to sign this form.

________________________ _____________________________________________ __________________________________________ Today’s Date PRINT name of cattle owner or representative SIGNATURE of cattle owner or representative

The Beef Promotion and Research Act of 1985 (Act) and the Beef Promotion and Research Order (Order) require collection of a mandatory $1-per-head beef checkoff assessment every time cattle are sold. The Act and Order authorize Qualified State Beef Councils (QSBCs) to collect the $1-per-head assessment. The law requires that at least 50 cents per head of the mandatory $1-per-head checkoff assessment be forwarded to the Cattlemen’s Beef Promotion and Research Board (Board) to help fund the Beef Checkoff Program, while the remaining portion can be retained by QSBC. A preliminary injunction granted by the Court enjoined USDA from continuing to allow the Montana Beef Council (MBC) to use the assessments that it collects under the Beef Checkoff Program to fund its advertising campaigns, unless a cattle producer provides prior affirmative consent authorizing MBC to retain a portion of the cattle producer’s assessment for State promotion, research, and information programs authorized under the Act. As a result of this preliminary decision, at this time, the full $1-per-head assessment collected by MBC must be remitted to the Board unless a producer provides prior affirmative consent authorizing MBC to retain up to 50 cents of the cattle producer’s assessment for State promotion, research, and information programs.

Producers who want up to 50 cents of their Federal $1-per-head assessment to remain with their State beef council must complete this form on an annual basis. The form must be completed each calendar year by January 1. If the form is received by the State beef council by January 1, the State beef council will be authorized to retain up to 50 cents of the Federal $1-per-head assessment during the entire calendar year. If it is received by the State beef council after January 1, the State beef council will be authorized to retain up to 50 cents of the Federal $1-per-head assessment for the remaining days of the year, beginning on the date the form was received by the State beef council. Forms should be submitted to [Insert name of State beef council, business address, telephone number, fax number, and email address.]

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 OMB control number for this information collection is OMB 0581-0093. The time required to complete this information collection is estimated to average 5 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.

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-2 (Expiration Date XX/XX/XXXX)