PSD- 4000 Weigher's Acknowledgement & Agreement

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

OMB Control No. 0581-0308

WEIGHERS’S ACKNOWLEDGEMENT
AND AGREEMENT

I,___________________________________________________________________________,
(1) Weigher’s Name
weighing for _________________________________________________________________,
(2) Entity Name
at ______________________________________, _________________________, as a weigher
(3) City
(4) State
have read and received the Instructions for Weighing (Livestock or Live Poultry and Feed), issued
under the authority of the Packers and Stockyards Act, 1921, as amended and supplemented.
(5) Select the statement that applies:
I acknowledge receipt of Instructions for Weighing Livestock and agree to follow the
instructions (9 CFR 201.73-1). Information held confidential (9 CFR 201.96).
I acknowledge receipt of Instructions for Weighing Live Poultry and Feed, and agree to
follow the instructions (9 CFR 201.108-1). Information held confidential (9 CFR 201.96).
I am aware that it is an offense against the United States to willfully make any false entry of weight
or other information on a scale ticket or other record used by the entity.
(6) Signature of Weigher:
(7) Signature of Authorized Entity:

(8) Date:

The entity for whom the weigher is weighing must:
Send one copy of the agreement to the Regional Office of the Agricultural Marketing Service, Fair
Trade Practices Program, Packers and Stockyards Division, USDA
Retain one copy for the weigher named on this agreement.
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 .24 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 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:
(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 4000

Expires XX/XX/XXXX

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Instructions to Complete
Weigher’s Acknowledgement and Agreement
Form PSD 4000
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.
A copy of this form must be retained by the entity.
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]
Areas Covered
Areas Covered
Areas Covered
AL, AR, CT, DC, DE, FL, GA,
IA, IL, IN, KY, MI, MN, MO,
AK, AZ, CA, CO, HI, ID, KS,
LA, MA, MD, ME, MS, NC,
ND, NE, OH, SD, WI
MT, NM, NV, OK, OR, TX,
NH, NJ, NY, PA, PR, RI, SC,
UT, WA, WY
TN, VA, VT, WV
If you have any questions about the form or completing the form, please contact the PSD Regional
Office that covers your area, as listed above. 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.
Line
No.
1
2
3
4
5

Subject

Instruction

Name
Entity Name
City
State
Select the Statement

Enter the name of the weigher.
Enter the name of the entity the weigher is weighing for.
Enter the city where the weigher will be weighing.
Enter the state where the weigher will be weighing.
Place a check in the box that applies to which Instructions
for Weighing has been acknowledged and agreed to.
The weigher must sign the form.
An authorized party of the entity must sign the form.

6
7

Weigher Signature
Entity Signature

8

Date

Form PSD 4000

Enter the date that Weigher’s Acknowledgement and
Agreement was signed.

Expires XX/XX/XXXX

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