OMB CONTROL NO. 0581-0308 

U.S. Department Of Agriculture 

Agricultural Marketing Service 

Fair Trade Practices Program 

Packers and Stockyards Division 

Claim Form for Livestock Sold on Commission 

(Clause 1) 

Issued Under Provisions of The Packers and 

Stockyards Act, 1921, as Amended and 

Supplemented 

State of (1) 

County (2) 

As the undersigned, I, (3) 

(full name of claimant) 

Of (4) 

(Street, City, State, and Zip+4) 

(5) 

(phone: home, cell) 

(other contact information: fax number, email address) 

being duly sworn, depose and state: 

I make this claim to (6) 

(name of surety or trustee, if applicable) 

Select One: 

under the bond issued by (7a) 

 

 

 

 

 

□ 

□ 

□ 

(name of surety company) 

under the Trust Fund Agreement held by (7b) 

(name of trustee) 

under the Trust Agreement held by (7c) 

(name of trustee) 

on behalf of (8) 

(full name and address of principal named in the instrument checked above) 

in the amount of (9) , which is the proceeds from livestock sold by 

(10) 

(full name and address of selling agency/registrant) 

Form PSD 2110 Expires 01/31/2025 Page 1 of 3
 

OMB CONTROL NO. 0581-0308 

for my account on a commission basis. 

(11) 

Date of Sale Number of Head Description of Livestock Amount 

$ 

Attached and made a part of this claim are copies of the account of sale and other 

documents covering the livestock transaction, such as copies of checks issued and other 

documents indicating the consignment of the livestock in question to such agency for 

which payment has not been made. (If full and complete documents of the transaction are not 

available or if these documents have become lost or destroyed, the claimant should insert a statement 

below of the facts in such respect:) 

(12) 

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OMB CONTROL NO. 0581-0308 

None of the claimed amount has been paid, and there are no setoffs or counterclaims to 

the same. 

I hereby authorize the Agricultural Marketing Service, Fair Trade Practices Program, 

Packers and Stockyards Division to release this proof of claim form and all of the attached 

supporting documents to the trustee or other interested parties to facilitate the processing 

of my claim. 

(13) 

(signature and title of claimant) 

(14) Subscribed and sworn to before me this day ______ of , 20____. 

(15) 

(signature of notary) 

(16) Notary Public for the State of: __________________________ 

(17) Residing at: 

My Commission expires: 

(18) (seal) 

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 collection is estimated to average 1.5 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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