Form LPS-76 Shell Egg Surveillance Quarterly Cost Rept.

(See reverse of Form for Privacy Act Statement)

OMB APPROVED: NO. 0581-0113
The information is needed as a basis of payment for performing shell egg
surveillance work. Response is required to obtain payment (7 CFR 57).

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
LIVESTOCK AND POULTRY PROGRAM

INSTRUCTIONS: Send copy to reach the applicable supervisor no later than the
20th of the month following the end of the reporting quarter. Retain a copy for your
records.

SHELL EGG SURVEILLANCE
QUARTERLY COST REPORT

2. REPORTING QUARTER (From-Thru)

1. COOPERATING AGENCY (Name and Location)

ACTUAL DIRECT COSTS
3. PERSONNEL SALARY COSTS
Travel Hours

Work Hours

Total Hours

Total Cost

a. Inspector
b. Supervisor
c. Clerical
d. Total Personnel Salary Costs (a+b+c) ………………………………….
4. FRINGE BENEFITS
e. Line d times

Explanation
% Percentage Rate…………………….
Explanation - Other Travel Costs

5. TRAVEL COSTS
f. Total miles_____________ times $_____________ per mile……………
g. Lodging and meals………………………………………………………...
h. Other travel costs (Explain)……………………………………………….
i. Total Travel Cost (f+g+h) ….……………………………………………
6. OTHER COSTS

Explanation

j. Telephone (Explain)……………………………………………………….
k. Supplies (Explain)…………………………………………………………
l. Miscellaneous (Explain)…………………………………………………...
m. Total Other Costs (j+k+l)
7. TOTAL ACTUAL DIRECT COSTS (d+e+i+m) ………………………
INDIRECT COST (If Applicable)
8. Applicable portion of line 7 times

% Approved Percentage Rate

Calculation

9. TOTAL QUARTERLY COSTS (7+8) ……………………………….
10. REMARKS (continue on reverse if needed)

11. SIGNATURE OF STATE REPRESENTATIVE

12. TITLE

13. DATE

14. SIGNATURE OF SUPERVISOR

15. DATE

16. SIGNATURE OF COMPLIANCE OFFICER

17. DATE

LP-76 (XX/20XX) Supersedes LPS-76

EXP. DATE: XX/XX/XXXX

OMB APPROVED: NO. 0581-0113

NOTE: 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 0581-0113. The time required to complete this information collection is estimated to average1.5 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.
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-76 (XX/20XX) Reverse