OMB No. 0581-0093 

U.S. DEPARTMENT OF AGRICULTURE 

AGRICULTURAL MAKRETING SERVICE 

PORK PROMOTION INVESTMENT REPORT 

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 0581-0093. The time required to 

complete this information collection is estimated to average 1 hour 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. 

(USE LABEL PROVIDED) 

CHECK IF ADDRESS CHANGED 

ACCT.# 

NAME CHECK TO ORDER FORMS 

ADDRESS 

CITY REQUEST ON-LINE REGISTRATION 

STATE ZIP CODE _______ 

PHONE 

EMAIL ADDRESS 

Pork Producer Checkoff Investments are shared by national and State organization to conduct pork industry promotion, research, and consumer information programs. 

MARKET HOG/CULL SOWS/BOARS INVESTMENT 

State of Origin Number of Hogs Gross Market Value Promotion Assessment 

HD $ 

HD $ 

HD $ 

HD $ 

HD $ 

HD $ 

HD $ 

x .0035 of Gross $ 

x .0035 of Gross $ 

x .0035 of Gross $ 

x .0035 of Gross $ 

x .0035 of Gross $ 

x .0035 of Gross $ 

Total: Total: $ 

FEEDER/ISOWEAN/PIG INVESTMENT 

State of Origin Number of Hogs Gross Market Value Promotion Assessment 

Total: 

HD $ x .0035 of Gross $

HD $ x .0035 of Gross $

HD $ x .0035 of Gross $

HD $ x .0035 of Gross $

HD $ Total: $

SEEDSTOCK INVESTMENT 

State of Origin Number of Hogs Gross Market Value Promotion Assessment 

HD $ 

HD $ 

HD $ 

x .0035 of Gross $

x .0035 of Gross $

Total: Total: $

DUE: 15 DAYS AFTER PERIOD ENDING DATE* TOTAL AMOUNT OF CHECK $ 

1.5% LATE CHARGE PER MONTH WILL BE BILLED 

PERIOD COVERED THRU 20 

(month/day) (month/day) 

Monthly reporting required on assessments of $25 per month. Assessments less than $25 during each month of a quarter may be reported 

quarterly. 

I hereby certify under penalty by law that the information contained in this Investment Report is true and accurate. 

Signature Date 

Now pay checkoff on-line by going to pork.org/pay or mail this form with the required information to: National Pork 

Board, 1776 Northwest 114th Street; Des Moines, Iowa 50325 

LP-101 (Expiration Date 11/30/2024) See reverse for burden/non-discrimination statement 
 

 

 

 

 

 

 

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the 

USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited 

from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual 

orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political 

beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all 

bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. 

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 Agency 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 

may be made available in languages other than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online 

at http://www.ascr.usda.gov/complaint_filing_cust.html and 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: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil 

Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: 

program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender. 

LP-101 (Expiration Date 11/30/2024)