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OMB No. 0581-0308 

Business Entity ID Number For PSD Use Only PSD Bar Code Only 

U.S. Department of Agriculture 

Agricultural Marketing Service 

Fair Trade Practices Program 

Packers and Stockyards Division 

STATEMENT OF ASSETS, LIABILITIES, 

AND EQUITY SPECIAL REPORT 

Instructions: If an item's value is zero, enter "0". If an item does not apply, enter "NA". If a line does 

not apply, enter "N/A". Return completed form to the appropriate P&SP regional office. See separate 

instructions for complete information about this report. 

GENERAL INFORMATION - SECTION 1 

101 Reporting Date 

(mm/dd/yyyy) 

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 I Fax Number 

111 E-Mail Address I 112 I Web Address 

ASSETS, LIABILITIES, AND EQUITY - SECTION 2 

ASSETS 

Current Assets: 

Cash (Enter overdrafts on line 223) 201 $ 

Overage in Custodial Bank Account (Enter shortage on line 224) 202 $ 

Current Cash Equivalents (CD's, Savings, etc.) 203 $ 

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

Owners, Officers, and Affiliated Companies 204 $ 

All Others (Sources Not Related to Company) 205 $ 

Total Trade Accounts Receivables-Net (Due in 1 year or less) (Total of lines 204 and 205) 206 $ 

Inventory: 

Livestock Inventory 207 $ 

Meat and Meat Products Inventory 208 $ 

Other Inventory 209 $ 

Total Inventories (Total lines 207, 208 and 209) 210 $ 

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

Owners, Officers, and Related Entities 211 $ 

Others (Sources Not Related to Company) 212 $ 

Total Notes and Loans Receivable (Due in 1 year or less) (Total lines 211 and 212) 213 $ 

Advances Made on Livestock, Meat and Meat Products 214 $ 

Other Current Assets 215 $ 

Total Current Assets (Total lines 201, 202, 203, 206, 210, 213, 214, and 215) 216 $ 

Property, Plant, & Equipment (Net of depreciation and amortization) 217 $ 

Other Assets: 

Investments in subsidiaries and affiliated companies 218 $ 

Due from Owners, Officers, and Related Entities (Due in 1 year or more) 219 $ 

Other Assets 220 $ 

Total Other Assets (Total lines 218, 219, and 220) 221 $ 

TOTAL ASSETS (Total lines 216, 217, and 221) 222 $ 

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OMB No. 0581-0308 

LIABILITIES 

Current Liabilities: 

Overdraft 223 $ 

Shortage in Custodial Bank Account 224 $ 

Trade Account Payables 

Livestock Payables (Due in 1 Year or Less) 225 $ 

Meat and Meat Products Payables (Due in 1 Year or Less) 226 $ 

Other Payables to Owners, Officers, and Related Entities (Due in 1 Year or Less) 227 $ 

Other Payables (Sources Not Related to Company) 228 $ 

Total Trade Account Payables (Total lines 225, 226, 227, and 228) 229 $ 

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 230 $ 

Others (Sources Not Related to Company) 231 $ 

Total Current Maturities of Long-Term Debt (Total lines 230 and 231) 232 $ 

Other Current Liabilities 233 $ 

Total Current Liabilities (Total lines 223, 224, 229, 232, and 233) 234 $ 

Other Liabilities: 

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

Owners, Officers, and Related Entities 235 $ 

Others (Sources Not Related to Company) 236 $ 

Total Long-Term Debt, Less Current Maturities (Total lines 235 and 236) 237 $ 

All Other Liabilities 238 $ 

TOTAL LIABILITIES (Total of lines 234, 237 and 238) 239 $ 

EQUITY 

Owner's Equity (Unincorporated) 240 $ 

OR 

Stock Issued (Incorporated) 241 $ 

Additional paid-in capital 242 $ 

Retained Earnings 243 $ 

TOTAL EQUITY (Total lines 240 through 243) 244 $ 

TOTAL LIABILITIES AND EQUITY (should equal line 222) 245 $ 

FINANCING INFORMATION - SECTION 3 

301 Is the entity liable for any contingent liabilities? Yes No If Yes, give brief explanation on line 302. 

302 

303 At the end of the reporting period, were Accounts Receivable and/or Inventories, or any part thereof, pledged or 

assigned as collateral under a financing or loan agreement? Yes No

 If the answer to 303 is "Yes", complete lines 304 through 308 for each financial lending institution. Attach additional sheets if more than one. 

304 Name of Lending Institution 

305 Mailing Address 

306 City, State, Zip +4 

307 Contact Name 

308 Contact Telephone Number 

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OMB No. 0581-0308 

309 Are Inventories collateralized under the agreement? Yes No 

310 Are Accounts Receivable collateralized under the agreement? Yes No 

311 Enter borrowing limit under the agreement $ 

312 Enter borrowing payable as of the end of the reporting period $ 

313 

At any time during the year, Have you been notified by your financial institution you were in violation 

of any covenants of your financial agreement? Yes No 

314 If so notified, have you been provided a waiver from your financial institution? Yes No 

315 Are any company owners, directors, officers or stockholders named as a guarantor under the agreement? Yes No 

316 If company is a subsidiary of another, is the Parent Company named as a guarantor under the agreement? Yes No 

Restrictions or covenants under financing or loan agreement 

317 Minimum cash balance to be maintained on deposit $ 

318 Minimum working capital to be maintained. $ 

319 Other (describe) 

Livestock Trust Ratio Calculation 

Reference the instruction sheet in calculating your Livestock Trust ratio 

320 Calculated Trust Ratio 

CERTIFICATION - SECTION 4 

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. 

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. 

401 Print Name 402 Signature 

403 Phone Number 404 Date 405 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, 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 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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