UNITED STATES DEPARTMENT OF AGRICULTURE

 OMB No. 0581-0093

AGRICULTURAL MARKETING SERVICE

SORGHUM, PROMOTION, 

RESEARCH, AND INFORMATION PROGRAM

A program of promotion, research, and consumer information 

designed to strengthen the sorghum industry.

NAME AND ADDRESS (include P.O. Box or Street, City, State, and ZIP)

Note: Information is required by 7 CFR 1221.116. Failure to 

report can result in a fine. Information is held confidential (7 CFR

1221.127).

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 15 

minutes 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. 

Privacy Act Notice Public Laws 95-113 and 93-579 permit 

collection of the data requested on this form. The information is 

used to identify entities that collect and remit assessments. 

REPORT AND REMITTANCE OF AMOUNT COLLECTED AND DUE ON SORGHUM PURCHASED

County Business Telephone (include area code)

The report and assessments must be remitted (postmarked) by the last day of the 

month following the end of the collection period. Late Payments are subject to a 

2 percent per month late payment charge. The following report is a report on 

sorghum purchased and the net market value paid for such purchases for the 

period commencing and ending . 

"Net market value" is the value found by multiplying the net 

market price (the sales price or other value, per volumetric unit 

received by a producer after adjustments for any premium or 

discount) by the appropriate quantity, bushels or tons, of 

sorghum. "Net market value" may also mean the minimum value 

in a production contract received by a sorghum producer.

GRAIN (Bushels)

STATE OF NUMBER OF BUSHELS PURCHASED NUMBER OF BUSHELS ASSESSED NET MARKET VALUE OF ASSESSED BUSHELS RATE TOTAL

ORIGIN

x .006 $

x .006 $

x .006 $

x .006 $

FORAGE (Tons)

STATE OF 

ORIGIN NUMBER OF TONS PURCHASED NUMBER OF TONS ASSESSED NET MARKET VALUE OF ASSESSED TONS RATE TOTAL

x .0035 $

x .0035 $

*NOTE: If remitting assessments past the due date, calculate the 2 percent mandatory 

late payment (compounded monthly).

Total Assessments x .02 = Late Payment

TOTAL ASSESSMENTS=

*LATE PAYMENT=

TOTAL REMITTANCE =

SEND THIS REPORT AND A CHECK IN THE TOTAL AMOUNT SHOWN ABOVE TO:

United Sorghum Checkoff Program 

4201 North Interstate 27

Lubbock, Texas 79403

806-687-8727

OFFICE USE ONLY

PENALTIES: You may, by law, be fined up to $10,000, 

imprisoned up to 5 years, or both for knowingly or willfully 

making false statements within this document.

(18 U.S.C. §1001).

CERTIFICATION STATEMENT

I declare, under the penalties provided by law, that this report has been examined by me; and to the best of my knowledge and belief is a true, correct and complete report.

NAME/TITLE (Print or type) SIGNATURE DATE

 LP-378 (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-378 (Expiration Date 11/30/2024)