Instructions to Complete

Claim Form for Livestock Sold 

Clause 2, 3, & 4

Form PSD 2120

Any person damaged by failure of a livestock buyer (referred to as the Principal) to pay for livestock 

purchased in a transaction subject to jurisdiction under the Packers and Stockyards Act has the right to 

submit a claim against the financial instrument of the Principal. This form may be used to submit a claim 

against the Principal's financial instrument.

Submit two copies of the completed notarized form with accompanying documentation, to the PSD regional 

office that covers your area. The Areas covered by each regional office are listed below the regional 

office's address. A copy of the completed notarized form and accompanying documentation should be 

retained for the complainant's files. 

Regional Offices of the Packers and Stockyards Division 

Agricultural Marketing Service, Fair Trade Practices Program

Eastern Regional Office

75 Ted Turner Drive SW, Ste 230 

Atlanta, GA 30303-3308 

Telephone: (404) 562-5840 

FAX: (404) 562-5848 

E-mail:

PSDAtlantaGA@ams.usda.gov

States Covered

AL, AR, CT, DC, DE, FL, GA, 

LA, MA, MD, ME, MS, NC, 

NH, NJ, NL, NY, PA, PR, QC, 

RI, SC, TN, VA, VT, WV

Midwestern Regional Office

210 Walnut Street, Room 317 

Des Moines, IA 50309-2110 

Telephone: (515) 323-2579 

FAX: (515) 323-2590 

E-mail:

PSDDesMoinesIA@ams.usda.go

States Covered

IA, IL, IN, KY, MB, MI, MN, 

MO, ND, NE, OH, ON, SD, WI

Western Regional Office

3950 Lewiston St., Suite 200 

Aurora, CO 80011-1556 

Telephone: (303) 375-4240 

FAX: (303) 371-4609 

E-mail:

v PSDDenverCO@ams.usda.gov

States Covered

AB, AK, AZ, BC, CA, CO, HI, 

ID, KS, MT, NM, NV, OK, OR, 

SK, TX, UT, WA, WY

If you have questions regarding completion of any portion of the bond claim form, please contact the PSD 

Regional Office that covers your area for assistance, as listed above.

In most instances, the PSD regional office will complete line numbers 6, 7, 8, 10, and 11. This is not a 

requirement, and the claimant may complete those items of the form, if known. 

The claimant(s) must complete line numbers 1, 2, 3, 4, 5, 9, 12, 13, and 14, and must sign line 15. 

A NOTARY PUBLIC must complete line numbers 16, 18, 19 and 20, and sign line 17. 

Line 

No.

Subject Instruction

1. State Enter the area where you live.

2. County Enter the county where you live.

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Line 

No.

Subject Instruction

3. Full Name of Claimant Enter your full name or your firm’s name, respectively, as the 

person(s)/firm making claim against the Principal’s bond or financial 

instrument.

4. Mailing Address Enter your complete mailing address, street, city, state and zip+4

5. Phone/home/cell, other 

contact information

Enter your home/cell phone number(s). Enter any other contact 

information where you may be reached (fax number, email address) 

6. Name of Surety or 

Trustee, 

(if applicable)

If a trustee is named on the referenced bond or financial instrument 

(document), enter that name as listed on the document on file with 

the PSD. If a trustee is not required on the document, enter the name 

of the surety listed on the surety bond. If you do not know the name 

of the trustee, or whether a trustee is required, contact the PSD 

regional office that covers your area

7a. Name of Surety Company Enter the name of the surety company who wrote the bond for the 

Principal. If you do not know the name of the surety, contact the 

regional office of the PSD which covers your area.

7b. Name of Trustee - TFA Enter the name of the trustee, as listed on the financial instrument. If 

you do not know the name of the trustee, contact the regional office 

of the PSD which covers your area.

7c. Name of Trustee – TA Enter the name of the trustee, as listed on the financial instrument. If 

you do not know the name of the trustee, contact the regional office 

of the PSD which covers your area.

8. Full Name and Address of 

Principal Named 

Enter the name of the Principal, as listed on the financial instrument. 

Include the Principal’s full address. If you do not know the name of 

the Principal, contact the regional office of the PSD which covers 

your area.

9. Amount of Claim Enter the amount you are claiming against the Principal’s financial 

instrument. Be reminded that you may only file your claim for the 

amount of livestock sold, or other lawful charges, as allowed by 

9 C.F.R. 201.33 issued under the Packers and Stockyards Act, 1921, 

as amended and supplemented.

10. Full Name and Address of 

Buyer 

Enter the full name and address of the buyer that purchased the 

livestock. In many cases, this will be the same information as in 

Item 8. However, the buyer may be a person/firm otherwise not 

listed on the referenced bond. The buyer may be a packer buyer 

purchasing livestock under the packer’s bond, a clearee purchasing 

livestock under a clearing agency bond, or an employee or agent of a 

registered firm purchasing livestock for said firm.

11. Date of Sale, Number of 

Head, Description of 

Livestock, Sales Price

Using the available invoice(s) provided by the seller, or by the buyer, 

enter each of the date(s) the livestock was sold, the number of head 

sold, what type of livestock was sold, and the amount the livestock 

was sold for.

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Line 

No.

Subject Instruction

12. Statement of Facts NOTE: Attach copies of the account of sale and/or other documents 

covering the livestock transaction, copies of checks issued and 

unpaid for the livestock, and other instruments indicating the 

consignment of the livestock. If the documents for the transaction(s) 

are incomplete or unavailable, enter a statement of facts of the 

transaction(s) in this section.

13. Signature and Title of 

Claimant

Sign the claim form and enter your title, if applicable, in the presence 

of a notary public.

A Notary Public must complete Items 16, 17, 18, 19 and 20. 

14. Subscribed and Sworn Enter the date, month, and year the Notary signed the claim form.

15. Signature The Notary must sign line 17.

16. Notary Public for the State 

of

Enter the state where the Notary is licensed.

17. Residing at Enter the city where the Notary lives.

18. My Commission expires Enter the date the Notary’s commission expires.

THIS CLAIM MUST BE NOTARIZED BEFORE SUBMITTING TO DEPUTY 

ADMINISTRATOR, AGRICULTURAL MARKETING SERVICE, FAIR TRADE PRACTICES 

PROGRAM, PACKERS AND STOCKYARDS DIVISION.

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