QID Prices Paid Screener

PRICES PAID - SCREENER
			OMB No. 0535-0003 Approval Expires: 10/31/2020 Project Code: 171 QID: 050801
						NATIONAL AGRICULTURAL STATISTICS SERVICE

Field Office U.S. Department of Agriculture, Rm 5030, South Building 1400 Independence Ave., S.W. Washington, DC 20250-2000 Phone: 1-800-727-9540 Fax: 202-690-2090 E-mail: [email protected]

Please make corrections to name, address and ZIP Code, if necessary.

The information you provide will be used for statistical purposes only. Your responses will be kept confidential and any person who willfully discloses ANY identifiable information about you or your operation is subject to a jail term, a fine, or both. This survey is conducted in accordance with the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347 and other applicable Federal laws. For more information on how we protect your information please visit: https://www.nass.usda.gov/confidentiality.Response is voluntary

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 is 0535-0003. The time required to complete this information collection is estimated to average 10 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.

Please mail your report promptly in the enclosed postage paid envelope. Thank you for your cooperation.

Fuel

1. Does this operation sell Fuel to farmers in the U.S.?

Yes. What was the total value of fuel sales for last year? $ __________

No. Go to Item 2.

Feed 2 Does this operation sell Feed to farmers in the U.S.?
Yes What was the total value of feed sales for last year? $ ___________ No. Got to Item 3
Seed 3 Does this operation sell Seed to farmers in the U.S.?
Yes What was the total value of seed sales for last year? $ ____________ No. Go to Item 4 OVER
Fertilizer and Chemicals 4 Does this operation sell Fertilizers or Agricultural Chemicals to farmers in the U.S.?
Yes. What was the total value of fertilizer and chemical sales for last year? $ ____________ No. Go to Item 5
Tractors and Farm Machinery 5 Does this operation sell NEW tractors or farm machinery to farmers in the U.S.? Yes. What was the total value of new tractors and farm machinery sales for last year $ _________ No. Go to Item 6

Type of Operation

6 Does this business operate at a single location or multiple locations?

One location. Multiple locations.

Multiple Locations. Please complete the following information if you operate at multiple locations.

List all addresses where this operation does business.

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

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Considering all the locations listed, how would you prefer to report?

Contact each site individually.

Headquarters reports for all locations on one report. Contact: ___________________________

Headquarters reports for all locations on separate reports. Contact: ___________________________

Reported by: _______________________ Date______________ Phone: (______) ______ - ___________

Office Use Only

Response

Respondent

Mode

Enum.

Eval.

R. Unit

Change

Office Use for POID

1-Comp 2-R 3-Inac 4-Office Hold 5-R – Est 6-Inac – Est 7-Off Hold – Est

9901

1-Op/Mgr 2-Sp 3-Acct/Bkpr 4-Partner 9-Oth

9902

1-Mail 2-Tel 3-Face-to-Face 4-CATI 5-Web 6-e-mail 7-Fax 8-CAPI 19-Other

9903

9998

9900

9921

9985

9989 __ __ __ - __ __ __ - __ __ __

Optional Use

9907

9908

9906

9916

S/E Name

1