LP-210P Poultry Products Grading Certificate

(See reverse side of form for OMB and EEO Statement)

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
Livestock and Poultry Program

POULTRY PRODUCTS
GRADING CERTIFICATE
APPLICANT (Name and address, including ZIP)

LOT NO.

NO.
CONTAINERS
PER LOT 1/

LOT NO.

NO.
CONTAINERS
EXAMINED

This certificate is receivable in all courts of the
United States as prima facie evidence of the truth of
the statements therein contained. This certificate
does not excuse failure to comply with any of the
laws and regulations enforced by the
United States Department of Agriculture.

NAME AND ADDRESS OF SHIPPER OR SELLER 1/

PRODUCT
(KIND, CLASS, TYPE, STYLE, SUBSTYLE)

TYPE AND CONDITION OF CONTAINERS

OMB APPROVED: NO. 0581-0128
CERTIFICATE NO.

PPA-

PLACE EXAMINED
PLANT NUMBER

NAME AND ADDRESS OF RECEIVER OR BUYER 1/

MARKDED
WEIGHT OF LOT 1/

WHERE HELD AND TEMPERATURE

TEST

TOTAL NET

Shortage
Overage

OFFICIAL U.S. GRADE

CONTAINERS WERE STAMPED WITH

ADDITIONAL CERTIFICATION
Product represented by this certificate meets specification requirements for:
Product derived from poultry of domestic origin.
_____________________________________________________________________
Certification determined by online sampling.
_____________________________________________DATED_________________
PURCHASE ORDER #

SALES ORDER #

ITEM #

The number of containers shown above was counted by the official grader.
Destination weight and temperature certification.
Test weighing performed on ______________________ at ________________ am/pm.

REMARKS:

CERTIFICATION STATEMENT

In compliance with the Regulations of the Secretary of Agriculture Governing the Grading of Poultry issued pursuant to the Agricultural Marketing Act of 1946, as amended, and any other Act of Congress
conferring like authority, it is certified that the product(s) listed hereon were examined and that the class, quality, quantity, and/ or condition of the product(s) at the time and on the date shown, were as stated above.

__________________________________________________________________________________________
OFFICIAL GRADER (Printed Name & Signature)

1/ As stated by applicant or contractor.

LP-210P (XX/20XX) (Previous LPS-210P editions may be used.)

________________________________________
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 0581-0128. The time required to complete this information collection is estimated to
average 3 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of
race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status,
religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's
income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with
disabilities who require alternative means for communication of program information (Braille, large print, audiotape,
etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination,
write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call
(800) 795-3272 (voice) or (202) 720-6382 (TDD).
USDA is an equal opportunity provider, employer, and lender.

LP-210P (XX/20XX) Reverse