PSD 6100 Live poultry Dealer Disclosure Statement instructions 06 01 2022

Instructions to Complete
Live Poultry Dealer Disclosure Document
Form PSD 6100
This form is used by any entity engaged in business as a Live Poultry Dealer and is required by
Section 201.100 and 201.114 of the regulations under the Packers and Stockyards Act, 1921
(Act), as amended and supplemented, to provide poultry growers the required disclosure
information.
Submit the Live Poultry Dealer Disclosure Document, along with all required disclosure
documents to each of the poultry growers under contract to you. 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.
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

Line No.
Subject
1
Company Name
2
Business Type

3

Operating Address

4

Contact Name

5

Telephone No.

6
7

E-mail Address
Website Address (if
applicable)
Grower Name

8

Instructions
Enter the legal name under which you are operating.
Enter the appropriate type of business organization as it
applies to the business operation. Examples of the business
types are Individual, Partnership, Corporation, LLC, LLP, or
Association.
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 on the disclosure information
Enter the telephone number where the contact person
may be reached.
Enter company’s e-mail address
Enter the complete Web site address the business operates.
For example: [email protected]
Enter the name of the poultry grower receiving the disclosure
documents.

9.

Term of Contract

10.

Disclosure 1
(Review statement)

11
a and b

Terms of poultry
Growing agreement

12
a and b

Disclosure 2(Review each
statement)

13

Disclosure 3

14a
14b

Company
Certification of
Agreement
Signature

14c

Date of Agreement

14d

Printed Name of
Contact
Title of Contact

14e
15
15a
15b
15c

Statement to Poultry
Grower
Grower Signature
Date signed
Printed Name

a. Enter the beginning date of the contract
b. Enter the ending date of the contract
The information in this disclosure statement 1 is regarding
the number of flocks, the density or number of birds placed,
and the target weight at which the poultry is caught.
a. The Live Poultry Dealer enters the minimum number of
flocks that will be placed on the growers’ farm each year.
b. The Live Poultry Dealer enters the minimum stocking
density of the flocks that will be placed on the growers’ farm
each year.
The Live Poultry Dealer will select the applicable statement
based on whether (a)the agreement does not contain new or
modified housing specifications that require original or
additional capital investment or (b) the agreement requires
new or modified housing specifications that require original
or additional capital investment.
Information data for poultry grower’s review regarding the
poultry growing agreement.
The appropriate individual shall complete line (a) with the
Company Name
The appropriate individual shall complete line (b) with the
signature of the Contact with the Company.
The appropriate individual shall complete line (c) with the
date the agreement is signed.
The appropriate individual shall complete line (d) with
the printed name of the Contact with the Company.
The appropriate individual shall complete line (e) with the
Title of the Contact with the Company.
Should be reviewed by Poultry Grower
The poultry grower will sign the document
Date the poultry grower signs the agreement
Printed name of the poultry grower