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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 DEALER OR 

MARKET AGENCY BUYING 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? If yes, complete line 209. Yes No

209 a. Manufacturer b. Model c. Serial Number

210 Does the entity use another company's scale to purchase livestock? If yes, complete line 211. Yes No

211 Entity Name: Entity Address:

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

213 Is this business owned or controlled by another business entity? If Yes, complete line 214 Yes No

214 Entity Name: Entity Address:

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OMB Control No. 0581-0308

215 Does the reporting Business, including any Owners, Officers, Directors, Members or Employees, own an

interest in any other Market Agency, Dealer Organization, or Packing Company? Yes No

If line 215 is yes, give the name of related firms, name of person or firms with relationship, and percentage of ownership under lines 216-220

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

216

217

218

219

220

VOLUME INFORMATION - SECTION 3

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

301 Cost of livestock purchased on a dealer

basis for registrant's account $ $ $ $ $

302 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)

303

Cost of livestock purchased as a dealer,

per quarter (Total of 303e should equal

301e)

$ $ $ $ $

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

304

Cost of livestock bought on commission

for the account of others regardless of

who paid for the livestock

$ $ $ $ $

305

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)

306

Cost of livestock bought on commission,

per quarter (Total of 306e should equal

304e)

$ $ $ $ $

307 Total Cost of Livestock Purchased (line 301e + line 304e) $

308 Number of days livestock was purchased during the reporting year

CLEAREE AND CLEAROR DESIGNATIONS - SECTION 4

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

402 Provide the name of the clearor if line 401 is checked.

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

If the checkbox is selected on line 403, you must enter the required information for lines 404-414

Clearee's Name as Registered Dollar Value of Livestock Purchased

404 405 $

406 407 $

408 409 $

410 411 $

412 413 $

Total Livestock Purchases of all Clearees 414 $

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OMB Control No. 0581-0308

STATEMENT OF ASSETS, LIABILITIES, AND EQUITY - SECTION 5

All CLEAREES, and DEALERS and/or order buyers whose total of line 307 equals less than $2.6 million may continue to Section 7, and do not need to 

complete Sections 5 and 6. All CLEARORS must complete Sections 5 and 6, regardless of the total cost of livestock purchased. 

ASSETS

Current Assets:

Cash (Enter overdrafts on line 521) 501 $

Current Cash Equivalents (CD's, Savings, etc.) 502 $

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

Owners, Officers, and Affiliated Companies 503 $

All Others (Sources Not Related to Company) 504 $

Total Trade Accounts Receivables-Net (Due in 1 year or less) (Total lines 503 and 504) 505 $

Inventory:

Livestock Inventory 506 $

Other Inventory 507 $

Total Inventories Total lines 506 and 507) 508 $

Notes and Loans Receivable (Due in 1 year or less):

Owners, Officers, and Related Entities 509 $

Others (Sources Not Related to Company) 510 $

Total Notes and Loans Receivable (Due in 1 year or less) (Total lines 509 and 510) 511 $

Advances Made on Livestock 512 $

Other Current Assets 513 $

Total Current Assets (Total lines 501, 502, 505, 508, 511, 512 and 513) 514 $

Property, Plant, & Equipment Net of Depreciation and Amortization 515 $

Other Assets:

Investments in Subsidiaries and Related Companies 516 $

Due from Owners, Officers, and Related Entities (Due in 1 year or more) 517 $

Other Assets 518 $

Total Other Assets (Total lines 516, 517, and 518) 519 $

TOTAL ASSETS (Total lines 514, 515, and 519) 520 $

LIABILITIES

Current Liabilities:

Overdraft 521 $

Trade Accounts Payables:

Livestock Payables (Due in 1 Year or Less) 522 $

Other Payables to Owners, Officers, and Related Entities (Due in 1 Year or Less) 523 $

Other Payables (Sources Not Related to Company)(Due in 1 Year or Less) 524 $

Total Trade Accounts Payables (Total lines 522, 523, and 524) 525 $

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 526 $

Others (Sources Not Related to Company) 527 $

Total Current Maturities of Long-Term Debt (Total lines 526 and 527) 528 $

Other Current Liabilities 529 $

Total Current Liabilities (Total lines 521, 525, 528 and 529) 530 $

Other Liabilities:

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

Owners, Officers, and Related Entities 531 $

Others (Sources Not Related to Company) 532 $

Total Long-Term Debt, Less Current Maturities (Total lines 531 and 532) 533 $

All Other Liabilities 534 $

TOTAL LIABILITIES (Total of lines 530, 533, and 534) 535 $

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OMB Control No. 0581-0308 

EQUITY 

Owner's Equity (Unincorporated) 536 $ 

OR

 Stock Issued (Incorporated) 537 $ 

Additional Paid-in Capital 538 $ 

Retained Earnings 539 $ 

TOTAL EQUITY (Total lines 536 through 539) 540 $ 

TOTAL LIABILITIES AND EQUITY (Total lines 535 and 540) (should equal line 520) 541 $ 

 STATEMENT OF REVENUES AND EXPENSES - SECTION 6 

Gross Dealer Profit (+) or Loss (-) 601 $ 

Buying Commission 602 $ 

Other Income 603 $ 

Total Income 604 $ 

Total Expenses 605 $ 

Net Profit (+) or Loss (-) 606 $ 

CERTIFICATION - SECTION 7 

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, and that 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.) 

701 Print Name 702 Signature 

703 Phone Number 704 Date 705 Title 

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). 

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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