LPS-518-1 Alleged Violation and Detention Notice

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

ALLEGED VIOLATION AND DETENTION NOTICE
1. NAME AND ADDRESS OF VIOLATOR

OMB APPROVED: NO. 0581-0113
The authorities for requesting the information to be supplied on this form and any
supplements are the Egg Products Inspection Act (21 USC 1031-1056) to provide a
mandatory inspection program & the Agricultural Marketing Act of 1946 (7 USC 16211627) to provide a voluntary grading program. This form is used to report alleged
violation(s) of the EPIA (Secs. 5,8,10,11,19, and 20) or the AMS (Sec. 203(h)) & as a
notice & record of detention of product in noncompliance with these Acts.

2. DATE OF REPORT

3. DATE OF VIOLATION

4. ALLEGED VIOLATION OF
EGG PRODUCTS INSPECTION ACT
AGRICULTURAL MARKETING ACT
VOLUNTARY REGULATIONS, PART___________________
OTHER______________________________________________
5. TYPE OF VIOLATION

6. DESCRIPTION OF PRODUCT(Class, type, state, number of containers, net weight, description of labels, USDA marks, grading/inspection sampling results, etc.)

Shipped
Received

7. CERTIFICATION: I certify (1) that the product described above was received or shipped by us as noted and (2) that the shipping records(s), if any, and
invoice(s), or copies thereof furnished to or copied by an authorized representative of the Secretary of Agriculture, cover the shipment(s) described.
8. PRINTED NAME, TITLE AND SIGNATURE OF AUTHORIZED AGENT IN RECEIPT OF REPORT
9. DATE

10. NAME AND ADDRESS OF SHIPPER

11. NAME AND ADDRESS OF RECEIVER OR BUYER

12. SHIPPING RECORDS INVOICES (Description and date, attach copy)

13. LOCATION OF PRODUCT

14. DISPOSITION OF PRODUCT (Detained, denatured, returned to seller, etc.)

15. PRINTED NAME AND SIGNATURE OF REGULATORY INSPECTOR

16. ADDRESS AND TELEPHONE OF REGULATORY INSPECTOR

IF PRODUCT IS DETAINED - COMPLETE ITEMS 17, 18, AND 19 BELOW
DETAINED TAG(S) ATTACHED TO PRODUCT
19. DETENTION NOTICE RECEIVED BY (Signature)
17. NUMBER(S)
18. DATE

The product described above is DETAINED by the Agricultural Marketing Service (AMS), U. S. Department of Agriculture (USDA), for a period not to exceed twenty (20) days in accordance
with the authority contained in the EPIA. The detention identification shall not be detached, defaced, or destroyed and the detained product shall not be removed from detention and used,
moved, or altered in any manner without first being released by an authorized representative of the AMS, USDA, under penalty of fine and/or imprisonment. Voluntary disposition of the
product to prevent its use as human food, or placing the product in compliance, will result in termination of the detention. Seizure, condemnation and disposal of such product shall be as
directed by any United States District Court or other proper court as provided in the EPIA.

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 average .25 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-518-1 (XX/20XX) Supersedes LPS-518-1

EXP. DATE: XX/XX/XXXX