PSD- 1500 Live Poultry Dealer Inquiry

OMB Control No. 0581-0308

U.S. Department of Agriculture
Agricultural Marketing Service
Fair Trade Practices Program
Packers and Stockyards Division

LIVE POULTRY DEALER INQUIRY

If an item's value is zero, enter "0". If an item does not apply, enter "NA". Upon completion please verify that
all items have been answered. Return completed form to the appropriate Regional Office. See separate
instructions for complete information about this report.
GENERAL INFORMATION - SECTION 1
101

Reporting Period
(mm/dd/yyyy)

b. TO

a. FROM

102 Entity Name
103 Trade Name/d.b.a
104 Mailing Address
105 City, State, Zip+4
106 Physical Address
107 City, State, Zip
108 Contact Name
109 Contact Telephone
111 Contact Telephone

111 E-Mail Address

112 Fax

112 Web Address

ORGANIZATIONAL STRUCTURE - SECTION 2
201 Type of organization:

Individual

Partnership

Corporation

202 List State Incorporated/Registered/Formed

L.L.C.

L.L.P.

Co-op

Association

Other

203 Date Incorporated/Registered/Formed

List owners, officers, partners, and members in control of this business
b. Title

a. Name

c. % Ownership

204
205
206
207
208
DESCRIPTION OF BUSINESS - SECTION 3
301 The poultry firm operates as (check all that apply)
Slaughterer

Processor

Broker (Live)

Dealer (Live)

Meat Dealer or Broker

LIVE POULTRY PURCHASES- SECTION 4
401 Did the firm purchase live poultry for slaughter? If yes, provide Establishment No.

Yes

No

403 Did the firm purchase live poultry to sell to a firm that slaughters?

Yes

No

404 Did the firm's purchases originate outside the state in which it was slaughtered?

Yes

No

402 FSIS Establishment No.

405 Total cost of live poultry purchased during the reporting period

Form PSD 1500

$

Expires XX/XX/XXXX

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OMB Control No. 0581-0308

LIVE POULTRY PRODUCED UNDER GROWING ARRANGEMENTS - SECTION 5
501 Did the firm obtain poultry using growing arrangements for its own slaughter?

Yes

No

502 Did the firm sell or contract poultry obtained using a growing arrangement?

Yes

No

503 Did any obtained poultry originate outside the state in which it was slaughtered?

Yes

No

504 Number of growers with growing arrangements (List the name of growers with growing arrangement under Remarks-Section 8.)
505 Estimated amount paid to growers under growing arrangements during the reporting period.

$

POULTRY PRODUCT SALES - SECTION 6
Did the firm process or prepare poultry products and then sell or ship those products
outside the state of slaughter?
Did the firm process or prepare poultry products and then sell or ship those products to the
602
U.S. Government?
601

Yes

No

Yes

No

POULTRY PRODUCT SOLD - SECTION 7
701 Total dollar amount of poultry and by-products sold during the reporting period.

$

REMARKS - SECTION 8
801 Use this space for additional information or explanation for any numbers items above, making reference to the item number.

CERTIFICATION - SECTION 9
Under the Packers and Stockyards Act any person who willfully makes, or causes any false entry or statement of fact in this report shall be deemed guilty of offense
against the United States, and be subject to a fine of $1,000 to $5,000, or to imprisonment for a term of not more than 3 years, or to both fine and imprisonment. Section
10 of the FTC Act, made applicable by Section 402 of the Act (7 U.S.C. 222).
I certify that this report has been prepared by me or under my direction, and to the best of my knowledge and belief
correctly reflects reporting entity operations.
901 Print Name
903 Phone Number

902 Signature
904 Date

905 Title

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 is 0581-0308 The time required to complete this information collection is
estimated to average .90 hours 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 law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the
basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.) 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 State or local Agency that administers the program 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 is also available in languages other than English.
To file a complaint alleging discrimination, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office or write a letter addressed to USDA and provided 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: (a) mail: U.S. Department of
Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (b) fax: (202) 690-7442; or (c) email:
[email protected].

Form PSD 1500

Expires XX/XX/XXXX

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Instructions to Complete
Live Poultry Dealer Inquiry
Form PSD 1500
This form is used by any entity engaged in business as a poultry dealer and is required by Section
201.94 and section 201.100 of the regulations under the Packers and Stockyards Act, 1921 (Act),
as amended and supplemented, to provide the information required by Form PSD 1500.
Penalties for willfully making, or causing to be made, any false entry or statement of fact in any
report required to be made under the Act include a fine between $1,000 to $5,000 or
imprisonment. Section 10 of the FTC Act, made applicable by Section 402 of the Act (7 U.S.C.
222).
Submit the completed form to the PSD regional office that covers your area. The Areas covered
by each regional office are listed below the regional office's address.
Regional Offices of the Packers and Stockyards Division
Agricultural Marketing Service, Fair Trade Practices Program
Eastern Regional Office
Midwestern Regional Office
Western Regional Office
75 Ted Turner Drive SW, Ste 230 210 Walnut Street, Room 317
3950 Lewiston St., Suite 200
Atlanta, GA 30303-3308
Des Moines, IA 50309-2110
Aurora, CO 80011-1556
Telephone: (404) 562-5840
Telephone: (515) 323-2579
Telephone: (303) 375-4240
FAX: (404) 562-5848
FAX: (515) 323-2590
FAX: (303) 371-4609
E-mail:
E-mail:
E-mail:
[email protected]
[email protected] [email protected]
States Covered
States Covered
States Covered
AL, AR, CT, DC, DE, FL, GA,
IA, IL, IN, KY, MB, MI, MN,
AB, AK, AZ, BC, CA, CO, HI,
LA, MA, MD, ME, MS, NC,
MO, ND, NE, OH, ON, SD, WI ID, KS, MT, NM, NV, OK, OR,
NH, NJ, NL, NY, PA, PR, QC,
SK, TX, UT, WA, WY
RI, SC, TN, VA, VT, WV
Additional copies of this form may be obtained from the regional office covering your area, or
on our website located at https://www.ams.usda.gov/resources/forms. All inquiries concerning
any section or part of a section contained in the form can also be addressed to the regional office.
Line
No.
101
102
103

Form PSD 1500

Subject

Instructions

GENERAL INFORMATION – SECTION 1
Reporting Period
Report covers the time from the start of your reporting
period (a. FROM) to the end of your reporting period (b.
TO)
Entity Name
Enter the name under which you are listed with PSD.
Trade Name/d.b.a.
Enter the trade name under which you operate. This is the
name the business uses, if applicable. If you do not operate
with a “Trade Name”, enter “N/A”.

Expires XX/XX/XXXX

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Line
No.
104
and
105

Subject
Mailing Address

106
and
107
108

Operating Address

109

Contact Telephone

110
111
112

Fax
E-Mail Address
Web Site Address
(if applicable)

Contact Name

Instructions
Enter your mailing address. Enter street, city, county, state,
and zip+4. This is the address where all correspondence,
regular and certified from the Packers and Stockyards
Division should be sent.
Enter the physical location of your operating address. Enter
street, city, state, and zip+4. This is the address where you
conduct your business services.
Enter the name of the person to be contacted regarding
questions on the report.
Enter the telephone where the contact person may be
reached.
Enter the Fax used by the entity.
Enter the entity’s e-mail address.
Enter the complete Web site address the business operates.
For example: [email protected]

ORGANIZATIONAL STRUCTURE – SECTION 2
201
Type of
Check the appropriate box to indicate the type of
Organization
organization as it applies to the business’ operation.
202
State Incorporated/
If appropriate, enter the state where the Corporation, LLC,
Registered/Formed
or LLP was formed.
203
Date Incorporated/
If appropriate, enter the date the Corporation, LLC, or LLP
Registered/Formed
was formed.
204a
Owners, Members,
For each owner, officer, member, and every partner, enter
Through Partners, Or
their name, title, and respective percentage of ownership.
208c
Officers, (Name and Provide this information for every individual with any
Title), Percent
ownership interest, 10% or greater, in the applicant’s
Ownership
operation. The person signing this report on line 902, must
be listed in this section.
DESCRIPTION OF BUSINESS– SECTION 3
301
Type of Operations Check the appropriate box to indicate what activities with
the poultry business your firm conducts.
LIVE POULTRY PURCHASES – SECTION 4
401
Purchased Live
Check the appropriate boxes) to indicate if the firm
Poultry
purchased live poultry for slaughter in the past year. If
“Yes” report the FSIS or State establishment number on line
402.
402
Establishment
Enter the FSIS or State Establishment number of the firm.
Number
403
Did firm purchase
Check the appropriate box to indicate if the firm purchased
live poultry to sell to poultry to sell to another firm that slaughters.
a firm that
slaughters?

Form PSD 1500

Expires XX/XX/XXXX

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Line
No.
404

Subject

Instructions

Did the firm’s
Check the appropriate box to indicate if the firm’s purchases
purchases originate
originated outside of the state in which it was slaughtered.
outside of the state
in which
slaughtered?
405
Total cost of live
Enter the total cost of all poultry purchased for the firm’s
poultry purchased
account for the past year.
for firm’s account in
a year
LIVE POULTRY PRODUCED UNDER GROWING ARRANGEMENTS– SECTION 5
501
Did firm obtain
Check the appropriate box to indicate if the firm obtained
poultry using a
poultry using a growing arrangement for the poultry’s own
growing
slaughter.
arrangement for its
own slaughter
502
Did firm sell or
Check the appropriate box to indicate if the firm sold or
contract poultry
purchased poultry obtained using a growing arrangement.
obtained using a
growing
arrangement
503

Did any poultry
Check the appropriate box to indicate if the poultry obtained
obtained originate
by the firm originated outside of the state in which the
outside of the state
poultry was slaughtered.
in which slaughtered

504

Growers with
growing
arrangements
Estimated yearly
value of the poultry
obtained under
growing
arrangements

505

601

Form PSD 1500

Enter the number of growers with growing agreements.
Enter the names of growers with growing arrangements in
the space provided under Remarks - Section 8.
Enter the estimated yearly dollar value of poultry obtained
under growing arrangements.

POULTRY PRODUCT SALES – SECTION 6
Did the firm sell or
Check the appropriate box to indicate if poultry products
ship any poultry
your firm manufactures or prepares are sold or shipped to
products
another state.
manufactured or
prepared by it
outside the state for
slaughter

Expires XX/XX/XXXX

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Line
No.
602

701

Subject
Did the firm sell or
ship any poultry
products
manufactured or
prepared by it to the
U.S. Government

Check the appropriate box to indicate if poultry products
your firm manufactures or prepares are sold or shipped to
the U.S. Government.

POULTRY PRODUCT SOLD – SECTION 7
Total Sales
Enter the total dollar amount of poultry products and byproducts sold during the last fiscal year.

801

Remarks

901

Print Name

902

Signature

903
904
905

Phone
Date
Title

Form PSD 1500

Instructions

REMARKS – SECTION 8
Enter additional information or provide explanations for any
numbered items above. Include the list of names of growers
with growing arrangements.
CERTIFICATION – SECTION 9
Print the name of the owner, officer, partner, or member
responsible for this report. The signor must be listed on
lines 204-208
The report must be signed by a responsible person, listed on
lines 204-208. Electronic signatures are considered valid.
Enter the phone of the person who signed the report.
Enter the date the form is signed.
Enter the title of the person signing the form.

Expires XX/XX/XXXX

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