PSD- 3001 Annual Report of Dealer or Market Agency Buying on Commi

OMB Control No. 0581-0308

Business Entity ID Number

For PSD Stamp Only

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

PSD Bar Code Only

Select this box if you want to receive
electronic notification to file your
annual report. This will begin in the
next reporting cycle.

ANNUAL REPORT OF DEALER OR
MARKET AGENCY BUYING ON
COMMISSION

Electronic Filing

Instructions: If a line's value is zero, enter "0". If a line does not apply, enter "N/A". Return completed form to the PSD
Central Reporting Unit. If all lines are not completed when the form is received, the form will be returned. See separate
instructions for complete information about this report.
GENERAL INFORMATION - SECTION 1

101

Reporting Period
(mm/dd/yyyy)

a. FROM:

b. TO:

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

110 Fax Number

111 E-Mail Address

112 Web Address
ORGANIZATIONAL STRUCTURE - SECTION 2

List owners, officers, partners, and members in control of this business with their ownership percentage.
a. Name

b. Title

c. %

201
202
203
204
205
206 Type organization:

Individual

Partnership

Corporation

L.L.C.

L.L.P.

Co-op

Association

207 Is this the same organization type reported last year?

Yes

No

208 Does the entity own or operate a scale on which purchased livestock is weighed? If yes, complete line 209.

Yes

No

209 a. Manufacturer

b. Model

c. Serial Number

210 Does the entity use another company's scale to purchase livestock? If yes, complete line 211.
211 Entity Name:

Per Head

213 Is this business owned or controlled by another business entity? If Yes, complete line 214

Form PSD 3001

No

Entity Address:

212 What is the basis of payment made to the entity for most livestock you sell?

214 Entity Name:

Yes

Live Wt.
Yes

Dressed Wt./Carcass Basis
No

Entity Address:

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OMB Control No. 0581-0308

215

Does the reporting Business, including any Owners, Officers, Directors, Members or Employees, own an
interest in any other Market Agency, Dealer Organization, or Packing Company?

Yes

No

If line 215 is yes, give the name of related firms, name of person or firms with relationship, and percentage of ownership under lines 216-220
a. Name of Related Firm

b. Name of Person/Firm with Relationship

c. %

216
217
218
219
220

VOLUME INFORMATION - SECTION 3

Livestock Dealer Purchases

b. Hogs

a. Cattle

301

Cost of livestock purchased on a dealer
basis for registrant's account

302

Number of head of livestock purchased
on a dealer basis for registrant's account

$

Dealer Volume by quarter

Cost of livestock bought on commission
304 for the account of others regardless of
who paid for the livestock

$

$

c. Sheep & Goats

$

e. Total (a+b+c+d)
$

d. Horses & Mules
$

$

e. Total (a+b+c+d)

d. Fourth Quarter
$

$

b. Hogs

a. Cattle

d. Horses & Mules
$

c. Third Quarter

b. Second Quarter
$

$

Livestock Bought on Commission (BOC)

$

$

a. First Quarter

Cost of livestock purchased as a dealer,
303 per quarter (Total of 303e should equal
301e)

c. Sheep & Goats

e. Total (a+b+c+d)
$

Number of head of livestock bought on
305 commission for the account of others
regardless of who paid for the livestock
BOC Volume by quarter

a. First Quarter

Cost of livestock bought on commission,
306 per quarter (Total of 306e should equal
304e)

$

c. Third Quarter

b. Second Quarter
$

$

$

307 Total Cost of Livestock Purchased (line 301e + line 304e)

e. Total (a+b+c+d)

d. Fourth Quarter
$

$

308 Number of days livestock was purchased during the reporting year
CLEAREE AND CLEAROR DESIGNATIONS - SECTION 4

401 Select this box if you are a clearee (Cleared and under the bond coverage of another entity for your livestock purchases)
402 Provide the name of the clearor if line 401 is checked.
403 Select this box if you are a clearor providing clearing services for clearees.
If the checkbox is selected on line 403, you must enter the required information for lines 404-414
Dollar Value of Livestock Purchased

Clearee's Name as Registered
404

405

$

406

407

$

408

409

$

410

411

$

412

413

$

Total Livestock Purchases of all Clearees 414

$

Form PSD 3001

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OMB Control No. 0581-0308

STATEMENT OF ASSETS, LIABILITIES, AND EQUITY - SECTION 5

All CLEAREES, and DEALERS and/or order buyers whose total of line 307 equals less than $2.6 million may continue to Section 7, and do not need to
complete Sections 5 and 6. All CLEARORS must complete Sections 5 and 6, regardless of the total cost of livestock purchased.
ASSETS
Current Assets:
Cash (Enter overdrafts on line 521)

501

$

Current Cash Equivalents (CD's, Savings, etc.)

502

$

505

$

508

$

511

$

Advances Made on Livestock

512

$

Other Current Assets

513

$

Trade Accounts Receivables-Net (Due in 1 year or less):
Owners, Officers, and Affiliated Companies

503

$

All Others (Sources Not Related to Company)

504

$

Total Trade Accounts Receivables-Net (Due in 1 year or less) (Total lines 503 and 504)
Inventory:
Livestock Inventory

506

$

Other Inventory

507

$

Total Inventories Total lines 506 and 507)
Notes and Loans Receivable (Due in 1 year or less):
Owners, Officers, and Related Entities

509

$

Others (Sources Not Related to Company)

510

$

Total Notes and Loans Receivable (Due in 1 year or less) (Total lines 509 and 510)

Total Current Assets (Total lines 501, 502, 505, 508, 511, 512 and 513)

514

$

Property, Plant, & Equipment Net of Depreciation and Amortization

515

$

519

$

520

$

530

$

533

$

534

$

535

$

Other Assets:
Investments in Subsidiaries and Related Companies

516

$

Due from Owners, Officers, and Related Entities (Due in 1 year or more)

517

$

Other Assets

518

$

Total Other Assets (Total lines 516, 517, and 518)
TOTAL ASSETS (Total lines 514, 515, and 519)
LIABILITIES
Current Liabilities:
Overdraft

521

$

525

$

528

$

529

$

Trade Accounts Payables:
Livestock Payables

522

$

Other Payables to Owners, Officers, and Related Entities (Due in 1 Year or Less)

523

$

Other Payables (Sources Not Related to Company)(Due in 1 Year or Less)

524

$

Total Trade Accounts Payables (Total lines 522, 523, and 524)
Current Maturities of Long-Term Debt: (Demand notes and portion of long-term notes due in 1 year or less)
Owners, Officers, and Related Entities

526

$

Others (Sources Not Related to Company)

527

$

Total Current Maturities of Long-Term Debt (Total lines 526 and 527)
Other Current Liabilities
Total Current Liabilities (Total lines 521, 525, 528 and 529)
Other Liabilities:
Long -Term Debt, Less Current Maturities: (Due in 1 year or more)
Owners, Officers, and Related Entities

531

$

Others (Sources Not Related to Company)

532

$

Total Long-Term Debt, Less Current Maturities (Total lines 531 and 532)
All Other Liabilities
TOTAL LIABILITIES (Total of lines 530, 533, and 534)

Form PSD 3001

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OMB Control No. 0581-0308

EQUITY
Owner's Equity (Unincorporated)
OR

536

$

Stock Issued (Incorporated)

537

$

Additional Paid-in Capital

538

$

539

$

Retained Earnings
TOTAL EQUITY (Total lines 536 through 539)
TOTAL LIABILITIES AND EQUITY (Total lines 535 and 540) (should equal line 520)

540
541

$
$

Total Income

604

$

Total Expenses

605

$

Net Profit (+) or Loss (-)

606

$

STATEMENT OF REVENUES AND EXPENSES - SECTION 6

Gross Dealer Profit (+) or Loss (-)

601

$

Buying Commission

602

$

Other Income

603

$

CERTIFICATION - SECTION 7
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).

With my signature, I certify the information provided on this form is true and correct to the best of my knowledge and belief, and that I am an owner, officer, or have been
authorized by responsible management to certify this report. (This form must be signed by a person listed in lines 201-205.)

701 Print Name
703 Phone Number

702 Signature
704 Date

705 Title

Submitted information is confidential (9 CFR 201.96). Submitted information is confidential (9 CFR 201.96). Failure to report may result with a complaint filed against the
entity in a United States District Court charging the entity with violations of the Packers and Stockyards Act and seeking civil penalties as authorized by law per day until
report receipt. Section 10 of the FTC Act, made applicable by Section 402 of the Act (7 U.S.C. 222).
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 2 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 3001

Expires XX/XX/XXXX

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Instructions to Complete
Annual Report of Dealer or
Market Agency Buying on Commission
Form PSD 3001
Each individual, corporation, and association engaged in business as a dealer or market agency
buying livestock on a commission basis is required to file an annual report with the U.S.
Department of Agriculture, Agricultural Marketing Service, Fair Trade Practices Program,
Packers and Stockyards Division (hereinafter known as “PSD”) on Form PSD 3001, Annual
Report of Dealer or Market Agency Buying on Commission.
If you report on a calendar year basis, your form must be post marked/e-filed by April 15 each
year. If you file on a fiscal year basis, you must submit your Annual Report form by 90 days after
the close of your fiscal year. Requests for additional time to file this report must be received no
later than the applicable filing dates above. Failure to file this form may result with a complaint
filed against the entity in a United States District Court charging the entity with violations of the
Packers and Stockyards Act and seeking civil penalties as authorized by law for each day the report
is delinquent. (Section 10 of the FTC Act made applicable by Section 402 of the Act (7 U.S.C.
222)).
All items must be completed on this form in its entirety. Failure to do so will result in the
form being returned as incomplete. If available, you may provide financial statements as an
attachment to the fully completed annual report form.
For questions about Form PSD 3001, or additional copies of the form, please contact the PSD
Central Reporting Unit at 303-375-4264 or [email protected]. Forms and instructions are
also located on PSD's website at https://www.ams.usda.gov/resources/forms. Please fax the
completed form to the Central Reporting Unit at 314-457-4421/844-303-0332, email to [email protected] or mail to:
USDA PSD
P.O. Box 110639
Aurora, CO 80042

SECTION-BY-SECTION INSTRUCTIONS
FORM HEADER – BUSINESS ENTITY ID
Business Entity ID should be completed using information on the annual report letter or email.
FORM HEADER – ELECTRONIC FILING
By selecting the Electronic filing check box, you will receive an email reminder message from
our system to the address listed on line 111 of the form each year that you are required to file
your annual report. This email is a reminder your report is due and includes instructions for the
E-Forms website located at https://forms.sc.egov.usda.gov to complete and file your report. The
forms are also located on the PSD website at https://www.ams.usda.gov/resources/forms.

Form PSD 3001

Expires XX/XX/XXXX

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Line No.
101
a and b

102
103
104
and
105
106
and
107
108
109
110
111
112

201a
through
205c

206
207
208

Form PSD 3001

Subject

Instruction
GENERAL INFORMATION - SECTION
Reporting Period
The reporting year covers the period of time operated the
previous year, either calendar year or fiscal year. (FROM:
should be the beginning of your reporting year; TO: should
be the end of your reporting year, i.e., 01/01/20YY to
12/31/20YY)
If you recently registered, please enter the date you started
operating (FROM) and the end of your reporting year (TO).
If you cease operations and go inactive, the end of your
reporting year (TO) will be the last date of operation.
Entity Name
Enter the name under which you are registered 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”.
Mailing Address
Enter your mailing address. Enter street, city, state, and
zip+4. This is the address where all correspondence from
PSD should be sent.
Operating Address
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.
Contact Name
Enter the name of the person to be contacted regarding
questions on the annual report.
Contact Telephone
Enter the telephone where the contact person may be
reached.
Fax Number
Enter the Fax used by the entity.
E-Mail Address
Enter the entity’s e-mail address.
Web Site Address (if
Enter the complete Web site address the business operates.
applicable)
For example: [email protected]
ORGANIZATIONAL STRUCTURE – SECTION 2
Owners, Members,
For each owner, officer, member, and every partner, enter
Partners, Or Officers,
their name, title, and respective percentage of ownership.
(Name and Title),
Provide this information for every individual with any
Percent Ownership
ownership interest, 10% or greater, in the applicant’s
operation. The person signing this report on line 702, must
be listed in this section.
Type of Organization
Check the appropriate box to indicate the type of
organization as it applies to the business’ operation.
Same Organization
Check the appropriate box to indicate if your organization is
Reported
the same as operated the previous year.
Own or Operate a Scale Check the appropriate box to indicate if this entity owns or
operates a livestock scale.

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Line No.
209 a
through
209c
210

Subject
Manufacturer, Model,
Serial Number

Instruction
If 208 is Yes, list a. manufacturer, b. model, and c. serial
number of each scale the entity operates.

Other company’s scale

If you use another entity’s scale to purchase livestock mark
Yes and go to line 211.
If you marked Yes on line 210, insert the entity’s name and
address of the scale you use.
Check the appropriate box to indicate the basis of payment
for the majority of livestock sold.
Check the appropriate box to indicate if this entity is owned
or controlled by another business entity.
If line 213 is Yes, list the name and address of the
owner/controlling business.
Check the appropriate box to indicate if this entity, or any of
its owners, officers, directors, members or employees own
an interest in any other market agency, dealer business, or
packing company.
List the names of the related firms owned by the reporting
business.

211

Entity name and address

212

Payment

213

Business
Control/Ownership
Business Name and
Address
Interest in other Market
Agency, Dealer
Organization or Packing
Company
Related firms’ names

214
215

216a.
through
220a.
216b.
through
220b.
216c.
through
220c.

Person or firm with
Relationship

List the name of the person or firm with ownership or
control of the entity listed in column a.

Percentage

List the percentage of ownership/control held by the
person/firm listed in column b.

VOLUME INFORMATION – SECTION 3
NOTE: do not include the cost of livestock purchased by clearees in this section of the report.
Those figures are to be reported in section 4 of this report.
301
Cost of livestock
Enter the cost for each category of livestock, and the total
a through e purchased as a dealer
cost of livestock purchased on a dealer basis during the
reporting period.
302
Number of head of
Enter the number of head purchased for each category of
a through e livestock purchased as a livestock and the total number of head of livestock
dealer
purchased on a dealer basis during the reporting period.
303
Cost of livestock
Enter cost of livestock purchased as a dealer, per quarter.
purchased as a dealer,
(Total of 303e should equal 301e)
per quarter
304
Cost of livestock bought Enter the cost for each category of livestock and the total
a through e on commission (BOC)
cost of livestock purchased as an order buyer during the
reporting period. You must include all livestock that you
bought on commission (BOC) regardless whether you or
another entity paid for it.

Form PSD 3001

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Line No.
305
a through e

Subject
Number of head of
livestock bought on
commission (BOC)

306
a through e

Cost of livestock bought
on commission, (BOC)
per quarter

307

Instruction
Enter the number of head purchased for each category of
livestock and the total number of head of livestock
purchased as an order buyer during the reporting period.
You must include all livestock that you bought on
commission, (BOC) regardless whether you or another entity
paid for it.
Enter cost of livestock bought on commission (BOC), per
quarter. (Total of 306e should equal 304e)

Total cost of livestock
purchased

Enter the Total Cost of Livestock Purchased. This amount
should be equal to lines 301e plus 304e, (should also be
equal to line 303e plus line 306e.).
308
Number of days
Enter the number of days livestock was purchased as a
livestock purchased
livestock dealer and/or order buyer during the reporting year.
CLEAREE AND CLEAROR DESIGNATIONS – SECTION 4
401
Are you a clearee
Check box indicating if another business provides clearing
services for you. (You are cleared under the bond coverage
of another entity)
402
Name of clearor
If you checked the box on line 401, enter the name of the
clearing agent (clearor).
If you provide clearing services to other livestock dealers (clearees), you must provide each
clearee’s name and total dollar amount of livestock they purchased. Do not include
the amount reported on line 414 with those reported on lines 301 or 304. If 403 is not checked
skip lines 404-414 and go directly to Section 5.
403
Are you a clearor
Check box if you are a clearor providing clearing services to
people who are cleared under your bond coverage.
404
Clearee’s name and
List the name of each Clearee, and the gross dollar amount
through
dollar amount of
of livestock purchased by each clearee during the reporting
414
livestock purchased
period, regardless of who paid for it, on lines 404-413, and
total on line 414. Attach additional sheet if necessary. If
you are not providing clearing services, skip section 4 and go
to section 5.
STATEMENT OF ASSETS, LIABILITIES AND EQUITY – SECTION 5
This section must be completed on this form. Include only the Assets, Liabilities and Net Worth
of the reporting Entity. If available, you may provide financial statements as an attachment to
the fully completed annual report form.
All clearees, and dealers and/or order buyers whose total of line 307 equals less than $2.6 million
may continue to Section 7, and do not need to complete Sections 5 and 6. All Clearors must
complete Sections 5 and 6, regardless of the total cost of livestock purchased.
501

Cash

502

Cash Equivalents

Form PSD 3001

Enter the total book balances of all bank accounts. An
overdraft should be reported on line 521.
Enter the dollar amount of any current cash investments
(savings, securities, CD’s, etc.). Include only those
marketable securities that represent the cash available for
current operations and not otherwise pledged as security.

Expires XX/XX/XXXX

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Line No.
503

506

Subject
Trade Accounts
Receivables from
Owners, Officers, and
Affiliated Companies
Trade Accounts
Receivables from All
Others (Sources Not
Related to Company)
Total Trade Accounts
Receivable-Net (Due in
1 year or less)
Livestock Inventory

507

Other Inventory

508
509

512

Total Inventories
Notes and Loans
Receivable from
Owners Officers,
Related Entities
Notes and Loans
Receivable from All
Others (Sources Not
Related to Company)
Total Notes and Loans
Receivable (Due in 1
year or less)
Advances on Livestock

513

Other Current Assets

514

Total Current Assets

515

Property, Plant and
Equipment

516

Investments in
subsidiaries and related
companies
Due from owners,
officers and related
entities
Other Assets

504

505

510

511

517
518

Form PSD 3001

Instruction
Enter the dollar amounts owed by owners, officers, or
affiliated companies as a result of delivering goods or
services, and extending credit in the ordinary course of
business.
Enter the dollar amounts owed by customers as a result of
delivering goods or services, and extending credit in the
ordinary course of business.
Enter the sum total of lines 503 and 504.
Enter the dollar amount of livestock held for the purpose of
sale to customers.
Enter any merchandise, raw materials, work in process,
finished goods, operating supplies and ordinary maintenance
materials and parts other than livestock, to be consumed in
the business during the next year.
Enter the sum total of lines 506 and 507.
Enter the total dollar amount owed to the company by
owners, officers, or related entities that is due in 1 year or
less.
Enter the total dollar amount owed to the company by other
than owners, officers or related entities that is due in 1 year
or less.
Enter the sum total of lines 509 and 510.
Enter the dollar value of cash advances given for the
purchase of livestock.
Enter the dollar value of prepaid expenses and other assets
expected to be converted to cash or sold or consumed during
the next year.
Enter the sum total of lines 501, 502, 505, 508, 511, 512, and
513.
Enter the dollar value of land, buildings, plant, equipment
and amortizable assets less accumulated depreciation and
amortization.
Enter the total dollar value of any investments in subsidiaries
and related companies.
Enter the dollar value due from owners, officers, and related
entities that is expected to be received in more than 1 year
from the reporting date of this report.
Enter the total dollar value of all others assets expected to be
converted to cash, or sold or consumed in more than 1 year
from the reporting date of this report.
Expires XX/XX/XXXX

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Line No.
519
520
521
522
523
524
525
526

527
528
529
530
531

532

533
534
535
536
537
538
539
540

Form PSD 3001

Subject
Total Other Assets
Total Assets
Overdraft
Livestock Payables
Other Payables to
Owners, Officers, and
Related Entities
Other Payables (Sources
Not Related to
Company)
Total Payables
Current Maturities of
Long-Term Debt related
to Owners, Officers and
Related Entities
Current Maturities of
Long-Term Debt related
to Others
Total Current Maturities
of Long-Term Debt
Other Current Liabilities
Total Current Liabilities
Long-Term Debt, less
Current Maturities
related to Owners,
Officers, and Related
Entities
Long-Term Debt, less
Current Maturities
related to Others
(Sources Not Related to
Company)
Total Long-Term Debt,
Less Current Maturities
All Other Liabilities
Total Liabilities
Owner’s Equity
(Unincorporated)
Stock Issued
(Incorporated)
Additional paid-in
capital
Retained Earnings
Total Equity

Instruction
Enter the sum total of lines 516 through 518.
Enter the sum total of lines 514, 515, and 519.
Enter the total overdraft balances of all bank accounts.
Enter the total dollar amount you owe for livestock.
Enter the total dollar amount you owe to owners, officers,
and related entities, for other than livestock. (Due in 1 year
or less)
Enter the total dollar amount you owe to all vendors for
other than livestock. (Due in 1 year or less)
Total lines 522, 523, and 524
Enter dollar amount of notes and loans due by you to
owners, officers, and related entities in 1 year or less.
Enter the dollar amount of notes and loans due by you to
other than owners, officers, and related entities in 1 year or
less.
Enter sum total of lines 526 and 527.
Enter the total dollar amount of any accrued liabilities and
other current liabilities due within 1 year of the reporting
date of this report.
Enter the sum total of lines 521, 525, 528, 529.
Enter the total dollar amount of notes, mortgages, bonds, and
installments that are payable to owners, officers, and related
entities after 1 year.
Enter the total dollar amount of notes, mortgages, bonds, and
installments that are payable to other than owners, officers,
and related entities after 1 year.
Enter the sum total of lines 531 and 532.
Enter all other liabilities owed after 1 year.
Enter the sum total of lines 520, 530, 533, and 534.
If unincorporated, enter the dollar amount of the owner’s net
worth.
If incorporated, enter the dollar amount of stock issued.
If incorporated, enter the dollar amount of any additional
paid-in capital.
If incorporated, enter the retained earnings.
Enter the sum of lines 536 through 539. (should equal 520
less line 535)

Expires XX/XX/XXXX

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Line No.
541

601
602
603
604
605
606
701
702
703
704
705

Form PSD 3001

Subject
Total Liabilities and
Equity

Instruction
Enter the sum total of lines 535 and 540. (should equal line
520)

STATEMENT OF REVENUES AND EXPENSES – SECTION 6
Gross Dealer Profit or
Enter the gross profit or loss on dealer transactions.
Loss
Buying Commission
Enter the gross income dollar amount from buying
(BOC)
commissions.
Other Income
Enter the dollar amount of all other income during the
reporting period.
Total Income
Enter the sum total of lines 601 through 603.
Total Expenses
Enter the dollar amount of all expenses incurred during the
reporting period.
Net Profit or Loss
Subtract line 605 from line 604; enter the different as Net
Profit (+) or Net Loss (-).
CERTIFICATION – SECTION 7
Print Name
Print the name of the owner, officer, partner, or member
responsible for this report. Must be listed in lines 201-205.
Signature
The report must be signed by a responsible person.
Electronic signatures are considered valid.
Phone
Enter the phone of the person signing the report.
Date
Enter the date the report is signed.
Title
Enter the title of the person signing the report.

Expires XX/XX/XXXX

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