QSBC-1 Producer Redirection of National Checkoff Assessments (B

OMB No. 0581-0093

Beef Checkoff Program

Producer Redirection of Checkoff Assessments Form

T he Beef Promotion and Research Act and 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 (QSBC) to retain up to 50 cents per head of the mandatory $1-per-head checkoff assessment for in-State research and promotion programs conducted by the State beef council. The law requires that at least 50 cents of the mandatory $1-per-head checkoff assessment be forwarded to the Cattlemen’s Beef Promotion and Research Board (Beef Board) to help fund national beef checkoff programs. Producers may use this form to request that the QSBC send the full $1-per-head beef checkoff assessment from their individual cattle sales to the Beef Board and that the QSBC not retain any portion of the individual’s assessment for its direct programing efforts.

This “Producer Redirection of Checkoff Assessment Form” must be postmarked by the 15th of the month following

the month the cattle were sold and mailed to the appropriate QSBC.

PRODUCER REDIRECTION OF CHECKOFF ASSESSMENTS FOR ALL CATTLE MARKETED IN THE MONTH OF: , 20

Company: ________________________________________ Requested by: ______________________________________________

Address: __________________________________________________________________________________________________________

City: _____________________________________________ State: ___________________ Zip Code: ______________________________

Phone No.: ____________________________________________ Email: ___________________________________________________

Please attach a copy of documents supporting payment of the beef checkoff assessment

as required verification of each transaction listed below.

Name of Collecting Point that collected the Beef Checkoff Assessment	Date of Sale	Total Number of Head Assessed	Requested Redirection of State Portion of Checkoff Assessments to the Beef Board ($0.50/head)
Example: ABC Livestock Market	1/15/2020	20	$10.00 ($0.50 per head)
Total amount requested for redirection to the Beef Board

I declare under the penalties provided by law, that this “Producer Redirection of Checkoff Assessments Form” has been examined by me and, to the best of my knowledge, is true, correct and complete. I also certify that I am authorized to sign this form.

________________________________________________________ ___________________________________

RESPONDING OFFICIAL’S NAME (PRINT) DATE

______________________________________________________________ ________________________________________

TITLE (PRINT) SIGNATURE

QSBC-1 (Expiration Date XX/XX/XXXX) Page 1 of 2 See reverse for burden/non-discrimination statement

OMB No. 0581-0093

[QSBC Name] use only
[QSBC NAME] Approval for Processing:
Amount to be redirected to the Beef Board: $
	Signature		Date

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 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.

QSBC-1 (Expiration Date XX/XX/XXXX) Page 2 of 2