OMB Control No. 0581-0308

Business Entity ID Number For PSD Stamp Only PSD Bar Code Only

U.S. Department of Agriculture

Agricultural Marketing Service

Fair Trade Practices Program

Packers and Stockyards Division

STATUS OF CUSTODIAL BANK ACCOUNT FOR 

SHIPPERS' PROCEEDS SPECIAL REPORT

Instructions: If an item's value is zero, enter "0". If an item does not apply, enter "NA". Upon completion 

please verify that all items have been answered. Return completed form to the appropriate PSD regional 

office. See separate instructions for complete information about this report.

GENERAL INFORMATION - SECTION 1

101 Entity Name

102 Trade Name/d.b.a

103 Mailing Address

104 City, State, Zip

105 Physical Address

106 City, State, Zip + 4

107 Contact Name

108 Contact Telephone 109 Fax Number

110 E-Mail Address 111 Web Address

NOTE: When more than one custodial account is maintained by the firm, complete a separate form for each account.

CUSTODIAL ACCOUNT INFORMATION - SECTION 2

CUSTODIAL ACCOUNT DESIGNATION - SECTION 3

301 Attach copies of the first page of the bank statement, and a voided check from the account, showing the designation "Custodial Bank Account for 

Shippers Proceeds. 

ANALYSIS OF CUSTODIAL BANK ACCOUNT FOR SHIPPERS' PROCEEDS - SECTION 4

Date of Custodial Analysis ( as of mm/dd/yyyy) 401

Balance as per Bank Statement 402 $

Deposits in transit in mail or bank, but not on statement (Attach documentation) 403 $

Certificates of deposit and savings accounts designated as custodial funds and

 on deposit in the bank carrying the custodial account (Attach copy of CD 

 and account statement) 404 $

Proceeds on hand 405 $

Proceeds receivables (from Line 512a) 406 $

Total of Lines 402 through 406 407 $

201 Name of Bank

202 Mailing Address

203 City, State, Zip

204 Bank Contact Name

205 Bank Contact Telephone

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Continuation of Section 4

Outstanding checks and drafts that have not cleared bank 408 $

Proceeds due consignors of livestock for which checks have not yet been issued 409 $

Unpaid expense items deducted from consignors' proceeds remaining in account 410 $

Total of Lines 408 through 410 411 $

Overage or Shortage in Account (Subtract line 411 from line 407) 412 $

Accounts Receivable - (from line 513b) 413 $

PROCEEDS/ACCOUNTS RECEIVABLES - SECTION 5

CREDIT BUYERS - SECTION 6

Enter the name and address of all buyers for whom you have extended credit - Add an additional page if necessary

a. Name of credit buyer b. Address (street, city, state, zip+4)

601

602

603

604

A Proceed Receivable is money that is owed the market for the purchase of livestock that has not yet been collected. The auction market may carry these 

amounts as a Proceeds Receivable, owed to the market, until the close of the seventh day counted from the date of the sale. After the close of the seventh day 

subsequent to the sale date, the market must reimburse the custodial account for any uncollected funds and the item(s) may no longer be classified as a 

Proceeds Receivable when preparing the custodial account analysis (reconciliation). An exception to this 7 day rule is when the purchase is made by an 

owner, officer or employee of the market. The payment for purchases by these related parties must be made by the close of the next business day, and may no 

longer be classified as a Proceeds Receivable when preparing the custodial account analysis (reconciliation) after the close of the next business day, from the 

date of the sale. Additionally, any time the market extends credit to a buyer, (approves a buyer to pay other than by the close of the next business day) the 

auction market must reimburse the custodial account for the amount of the payment for which credit has been extended.

Is the buyer a 

market, owner, 

officer, employee, 

or credit buyer

a. Amount of Proceeds

Receivable

b. Amount of Accounts

Receivable Date of Sale Name of Buyer

501 $ $

502 $ $

503 $ $

504 $ $

505 $ $

506 $ $

507 $ $

508 $ $

509 $ $

510 $ $

511 Total from Additional Pages (enter 0 if no other pages used) $ $

512 Total Proceeds Receivable (enter on line 406) $

513 Total Accounts Receivable (enter on line 413) $

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OMB Control No. 0581-0308

CERTIFICATION - SECTION 7

Submitted information is confidential (9 CFR 201.96). Failure to report may result with a complaint filed against the entity in a United States District Court 

charging the entity with violations of the Packers and Stockyards Act and seeking civil penalties as authorized by law, until report receipt. Section 10 of the FTC 

Act made applicable by Section 402 of the Act (7 U.S.C. 222). Response is required in order to determine establishment, maintenance and status of custodial 

account (9 CFR 201.97). 

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 3 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 provided 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: program.intake@usda.gov.

Under the Packers and Stockyards Act any person who willfully makes, or causes any false entry or statement of fact in this report shall be deemed guilty of 

offense against the United States, and be subject to a fine of $1,000 to $5,000, or to imprisonment for a term of not more than 3 years, or to both fine and 

imprisonment.

With my signature, I certify the information provided on this form is true and correct to the best of my knowledge and belief, I am an owner, officer, or 

have been authorized by responsible management to certify this report. 

 701 Print Name 702 Signature 

703 Phone Number 704 Date 705 Title

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