QSSB-1 Producer Redirection of National Checkoff Assessments (S

OMB NO. 0581-0093

Producer Redirection of Checkoff Assessments Form

The Soybean Promotion, Research, and Consumer Information Act and Order require collection of a mandatory 0.5 percent of the net market price per bushel checkoff assessment every time soybeans are sold. The Act and Order authorize State soybean councils to retain 50 percent of the mandatory checkoff assessment (i.e., 0.25 percent of the net market price per bushel checkoff assessment) for in-State research and promotion programs conducted by the State soybean boards. The Act requires that half of the mandatory checkoff assessment be forwarded to the United Soybean Board (Soybean Board) to help fund national soybean checkoff programs. [State] producers may use this form to request that the [QSSB] send the full 0.5 percent of the net market price per bushel checkoff assessment from their individual soybean sales to the Soybean Board and that the [QSSB] 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 last day of the month following the month the soybeans were sold and mailed to the appropriate QSSB. PRODUCER REDIRECTION OF CHECKOFF ASSESSMENTS FOR ALL SOYBEANS MARKETED IN THE MONTH OF: ______________, 20_____

Company:

Requested by:

Address:

City:

State:

Zip Code:

Phone Number:

Email:

Please attach a copy of documents supporting payment of the soybean checkoff assessment as required verification of each transaction listed below.

Name of First Purchaser that collected the Soybean Checkoff Assessment

Date of Sale

Total Number of Bushels Assessed

Net Market Price (NMP) of Assessed Bushels

Requested Redirection of State Portion of Checkoff Assessments to the Soybean Board (0.25% of net market price per bushels sold)

Example: ABC Elevator

9/15/2020

1,000

$8,000 (NWP) (i.e., 1,000 x 8.00/bu = NWP)

$20.00 (i.e., $8,000 x .0025 (0.25%) of net market price per bushels sold)

Total amount requested for redirection to the Soybean 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.

______________________________________________________________________________________________________________

DATE RESPONDING OFFICIAL’S NAME (PRINT)

______________________________________________________________________________________________________________

TITLE (PRINT) SIGNATURE

[QSSB Name] use only
[QSSB NAME] Approval for Processing:
Amount to be redirected to the Soybean 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 0581-0294. 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.

QSSB-1 (Expiration Date XX/XX/XXXX) See reverse for burden/non-discrimination statement