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 

ANNUAL REPORT OF 

MARKET AGENCY SELLING 

ON COMMISSION 

Select this box if you want to receive 

electronic notification to file your annual 

report. This will begin in the next 

reporting cycle. 

Electronic Filing 

Instructions: If a line's value is zero, enter "0". If a line does not apply, enter "N/A". Return completed form to 

the PSD Central Reporting Unit. If all lines are not completed when the form is received, the form will be 

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

GENERAL INFORMATION - SECTION 1 

101 Reporting Period 

(mm/dd/yyyy) a. FROM: b. TO: 

102 Entity Name 

103 Trade Name/d.b.a. 

104 Mailing Address 

105 City, State, Zip+4 

106 Operating Address 

107 City, State, Zip+4 

108 Contact Name 

109 Contact Telephone 110 Fax Number 

111 E-Mail Address 112 Web Address 

ORGANIZATIONAL STRUCTURE - SECTION 2 

List owners, officers, partners, and members in control of this business with their ownership percentage. 

a. Name b. Title c. % 

201 

202 

203 

204 

205 

206 Type organization: Individual Partnership Corporation L.L.C. L.L.P. Co-op Association 

207 Is this the same organization type reported last year? Yes No 

208 Does the entity own or operate a scale on which purchased livestock is weighed? Yes No 

209 a. Manufacturer b. Model c. Serial Number 

210 What is the basis of payment made to the entity for most livestock you sell? Per Head Live Wt. Dressed Wt. or Carcass Basis 

211 Is this business owned or controlled by another business entity? If Yes, list information on line 212 Yes No 

212 Entity Name: Entity Address: 

213 Name and Version of software program used for consigner/buyer invoices 

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214 Does this Business, including any Owners, Officers, Directors, Members or Employees, own 

an interest in any other Market Agency, Dealer Organization, or Packing Company? 

 

□ □ 

□ 

B 

D 

OMB Control No. 0581-0308 

Yes No 

If line 214 is yes, give the name of related firms, name of person or firms with relationship, and percentage of ownership under lines 215-218 

a. Name of Related Firm b. Name of Person/Firm with Relationship c. % 

215 

216 

217 

218 

SELLING ON COMMISSION OPERATION (CLAUSE 1 BOND) - SECTION 3 

Livestock Sold at Market a. Cattle b. Hogs c. Sheep & Goats d. Horses & Mules e. Total (a+b+c+d) 

301 

Livestock consigned by others to your 

market (number of head) 

302 

Livestock consigned by you to your market 

(number of head) 

303 

Total livestock consigned to your market 

(number of head) 

304 

Gross value of livestock sold on 

commission $ $ $ $ $ 

305 NUMBER OF PUBLIC SALE DAYS COVERED BY THIS REPORT

DEALER AND BUYING ON COMMISSION OPERATION (CLAUSE 2 BOND) - SECTION 4 

Livestock Dealer Purchases a. Cattle b. Hogs c. Sheep & Goats d. Horses & Mules e. Total (a+b+c+d) 

401 

Cost of livestock purchased on a dealer 

basis for registrant's account $ $ $ $ $ 

402 

Number of head of livestock purchased on 

a dealer basis for registrant's account 

Dealer Volume by quarter a. First Quarter b. Second Quarter c. Third Quarter d. Fourth Quarter e. Total (a+b+c+d) 

403 

Cost of livestock purchased as a dealer, per 

quarter (403e is equal to 401e) $ $ $ $ $ 

Livestock Bought on Commission a. Cattle b. Hogs c. Sheep & Goats d. Horses & Mules e. Total (a+b+c+d) 

404 

Cost of livestock bought on commission 

(BOC) for the account of others regardless 

of who paid for the livestock $ $ $ $ $ 

405 

Number of head of livestock bought on 

commission for the account of others 

regardless of who paid for the livestock 

BOC Volume by quarter a. First Quarter b. Second Quarter c. Third Quarter d. Fourth Quarter e. Total (a+b+c+d) 

406 

Cost of livestock bought on commission, 

per quarter (406e is equal to 404e) $ $ $ $ $ 

407 Total Cost of Livestock Purchased - line 401e plus line 404e $ 

408 Number of days livestock was purchased during the reporting year 

CLEAREE AND CLEAROR DESIGNATIONS - SECTION 5 

501 Select this box if you are a clearee (Cleared and under the bond coverage of another entity for your livestock purchases) 

502 Provide the name of the clearor if line 501 is checked: 

503 Select this box if you are a clearor providing clearing services for clearees. 

If the checkbox is selected on line 503, you must enter the required information for lines 504-514 

Clearee's Name as Registered Dollar Value of Livestock Purchased 

504 505 $ 

506 507 $ 

508 509 $ 

510 511 $ 

512 513 $ 

Total Livestock Purchases of all Clearees 514 $ 

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OMB Control No. 0581-0308 

ANALYSIS OF CUSTODIAL BANK ACCOUNT FOR SHIPPERS' PROCEEDS - SECTION 6 

Date of Custodial Analysis ( as of mm/dd/yyyy - should be same as reporting year end) 601 

Balance as per Bank Statement 602 $

Deposits in transit in mail or bank, but not on statement 603 $

Certificates of Deposit/Savings designated as custodial funds 604 $ 

Proceeds on hand 605 $ 

Proceeds receivable 606 $ 

Total of Lines 602 through 606 607 $ 

Outstanding checks and drafts that have not cleared bank 608 $ 

Proceeds due consignors of livestock for which checks have not yet been issued 609 $ 

Unpaid expense items deducted from consignors' proceeds remaining in account 610 $ 

Total of Lines 608 through 610 611 $ 

Overage or Shortage in Account 612 $ 

Accounts Receivable - (from sales of livestock not classified as Proceeds Receivable) 613 $ 

STATEMENT OF ASSETS, LIABILITIES, AND EQUITY - SECTION 7 

Include values only for the reporting entity. 

ASSETS 

Current Assets: 

Cash in Non-Custodial Accounts (Enter overdrafts on Line 722) 701 $ 

Overage in Custodial Bank Account (From Line 612, if a positive amount) 702 $ 

Current Cash Equivalents (CD's, Savings, etc.) 703 $ 

Trade Accounts Receivable-Net (Due in 1 year or less): 

Owners, Officers, and Affiliated Companies 704 $ 

All Others (Sources Not Related to Company) 705 $ 

Total Trade Accounts Receivables-Net (Due in 1 year or less) (Total of lines 704 and 705) 706 $ 

Inventory: 

Livestock Inventory 707 $ 

Other Inventory (Inventory to be consumed in the business during the year) 708 $ 

Total Inventories (Total lines 707 and 708) 709 $ 

Notes and Loans Receivable (Due in 1 Year or Less): 

Owners, Officers, and Related Entities 710 $ 

Others (Sources Not Related to Company) 711 $ 

Total Notes and Loans Receivable (Due in 1 Year or Less) (Total lines 710 and 711) 712 $ 

Advances Made on Livestock 713 $ 

Other Current Assets 714 $ 

Total Current Assets (Total lines 701, 702, 703, 706, 709, 712, 713, and 714) 715 $ 

Property, Plant, & Equipment Net of Depreciation and Amortization 716 $ 

Other Assets: 

Investments in Subsidiaries and Related Companies 717 $ 

Due from Owners, Officers, and Related Entities (Due in 1 

year or more) 

Livestock Inventory not related to sales to customers 

(feeding, backgrounding, depreciable assets) 

718 $ 

719 $ 

Other Long-Term Assets 720 $ 

Total Other Assets (Total lines 717, 718, 719, and 720) 721 $ 

TOTAL ASSETS (Total of lines 715, 716, and 721) 722 $ 

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OMB Control No. 0581-0308 

LIABILITIES 

Current Liabilities: 

Overdraft 723 $ 

Shortage in Custodial Account (from line 612, if a negative amount) 724 $ 

Trade Account Payables: 

Livestock Payables (Due in 1 Year or Less) 725 $ 

Other Payables to Owners, Officers, and Related Entities (Due in 1 Year or Less) 726 $ 

Other Payables (Sources Not Related to Company)(Due in 1 Year or Less) 727 $ 

Total Trade Account Payables (Total Lines 725, 726, and 727) 728 $ 

Current Maturities of Long-Term Debt: (Demand notes and portion of long-term notes due in 1 year or less) 

Owners, Officers, and Related Entities 729 

730 

$ 

Others (Sources Not Related to Company) $ 

731 

732 

$ 

$ 

Total Current Maturities of Long-Term Debt (Total lines 729 and 730) 

Other Current Liabilities 

Total Current Liabilities (Total lines 723, 724, 728, 731, and 732) 

Other Liabilities: 

Long -Term Debt, Less Current Maturities: (Due in 1 year or more) 

Owners, Officers, and Related Entities 

Others (Sources Not Related to Company) 

Total Long-Term Debt, Less Current Maturities (Total lines 734 and 735) 

All Other Liabilities 

TOTAL LIABILITIES (Total of lines 733, 736, and 737) 

EQUITY 

Owner's Equity (Unincorporated) 

OR 

Stock Issued (Incorporated) 

Additional Paid-in Capital 

Retained Earnings 

TOTAL EQUITY (should equal lines 739 through 742) 

TOTAL LIABILITIES AND EQUITY (should equal line 722) 

733 $ 

734 

735 

$ 

904 Date: 

$ 

736 

737 

738 

$ 

$ 

$ 

739 $ 

740 

741 $ 

742 

$ 

$ 

743 

744 $ 

$ 

STATEMENT OF REVENUES AND EXPENSES - SECTION 8 

Selling Commissions of Market 801 $ 

Gross Dealer Profit (+) or Loss (-) 802 $ 

Buying Commission 803 $ 

Other Income 804 $ 

Total Income 805 $ 

Total Expenses 806 $ 

Net Profit (+) or Loss (-) 807 $ 

CERTIFICATION - SECTION 9 

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. 

Section 10 of the FTC Act, made applicable by Section 402 of the Act (7 U.S.C. 222). 

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. (This form must be signed by a person listed in lines 201-205.) 

901 Print Name: 902 Signature: 

903 Phone Number: 905 Title: 

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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 per day until report receipt. Section 10 of the 

FTC Act, made applicable by Section 402 of the Act (7 U.S.C. 222). 
 

OMB Control No. 0581-0308 

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 2 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. 

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