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 LIVE POULTRY 

DEALERS 

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 

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 Is this business owned or controlled by another business entity, if yes complete line 209 Yes No 

209 If line 208 is yes, identify the owner/controlling business name and address 

210 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 210 is yes, give the name of related firms, name of person or firms with relationship, and percentage of ownership under lines 211-215 

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

211 

212 

213 

214 

215 

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OMB Control No. 0581-0308 

FINANCIAL INFORMATION - SECTION 3 

Enter the name and location of the financial institution you use for grower or poultry payments. 

301 Name of Financial Institution 

302 Physical Address 

303 City, State, Zip+4 

304 Contact Name 305 Contact Telephone 

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

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

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

violation of any of the terms, conditions, and/or covenants of your financial agreement? Yes No 

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

309 If the financial institution named in line 301 is the same as that used for your financial or loan agreement, check 

this box. Otherwise, complete lines 310 through 314, as necessary. 

 If line 309 is checked, complete lines 310 through 314 for each financial lending institution. Attach additional sheets if more than one. 

310 Name of Lending Institution 

311 Mailing Address 

312 City, State, Zip +4 

313 Contact Name 314 Contact Telephone 

Poultry Trust Ratio Calculation 

Reference the instruction sheet in calculating your Poultry Trust ratio 

315 Calculated Trust Ratio 

OPERATING INFORMATION - SECTION 4 

ACTIVITIES ENGAGED IN (check all that apply) 

401 Producing poultry under grow out contracts for slaughter 

402 Producing poultry under marketing agreements for slaughter 

403 Producing poultry under either of the above growing arrangements for sale to another for slaughter 

404 Producing poultry under either of the above growing arrangements for slaughter by a custom slaughterer 

405 Custom poultry slaughterer 

406 Buying live poultry for slaughter (e.g. spent fowl plant) 

407 Buying live poultry for slaughter by a custom slaughterer 

408 Buying live poultry for resale to a slaughterer 

409 Buying live poultry for resale to a live bird market 

INPUT AND PRODUCT MARKETS 

410 Enter the number of active grow out contracts and marketing agreements on the last day of this reporting period ______________ 

411 Yes No Poultry purchased or obtained under growing arrangements performed outside the state in which it was slaughtered or sold?

412 Yes No Live poultry sold outside the state in which it was bought or obtained under a growing arrangement?

413 Yes No Poultry meat sold outside the state in which the poultry was slaughtered? 

LOCATION OF FACILITIES (attach additional page if needed). 

Slaughter Facility Name FSIS # Street, City, State, Zip+4 Phone 

414 

415 

416 

417 

418 

419 

420 

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OMB Control No. 0581-0308 

Feed Mill Name Street, City, State, Zip+4 Phone 

421 

422 

423 

424 

425 

426 

427 

428 

429 

430 

TOTAL SLAUGHTER - SECTION 5 

Total slaughter a. Chickens b. Turkeys c. Other 

Head Lbs. Head Lbs. Head Lbs. 

501 Poultry Grown under grow out contracts 

502 Poultry grown under marketing agreement 

503 Poultry grown by the company (e.g. 

company owned farms) 

504 Live Poultry purchased 

505 Total Poultry Procured (sum lines 501 to 

504) 

506 Live Poultry sold 

507 Total Poultry custom slaughtered by you 

for others 

508 Total slaughter (line 505 minus 506 plus 

507) 

STATEMENT OF ASSETS, LIABILITIES, AND EQUITY - SECTION 6 

ASSETS 

Current Assets: 

Cash (Enter overdrafts on line 619) 601 $ 

Current Cash Equivalents (CD's, Savings, etc.) 602 $ 

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

Owners, Officers, and Affiliated Companies 603 $ 

All Others (Sources Not Related to Company) 604 $ 

Total Trade Accounts Receivables-Net (Due in 1 year or less) (Total lines 603 and 604) 605 $ 

Inventory 606 $ 

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

Owners, Officers, and Related Entities 607 $ 

Others (Sources Not Related to Company) 608 $ 

Total Notes and Loans Receivable (Due in 1 Year or Less) (Total lines 607 and 608) 609 $ 

Other Current Assets 610 $ 

Total Current Assets (Total of lines 601, 602, 605, 606, 609, and 610) 611 $ 

Property, Plant, & Equipment Net of Depreciation and Amortization 612 $ 

Other Assets: 

Investments in Subsidiaries and Affiliated Companies 613 $ 

Due from Owners, Officers, and Related Entities (Due in 1 year or more) 614 $ 

Other Assets 615 $ 

Total Other Assets (Total of lines 613 through 615) 616 $ 

TOTAL ASSETS (Total of lines 611, 612, and 616) 617 $ 

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OMB Control No. 0581-0308 

LIABILITIES 

Current Liabilities: 

Overdraft 618 $ 

Payables to Owners, Officers, and Related Entities (Due in 1 year or Less) 619 $ 

Other Payables (Sources Not Related to Company) (Due in 1 Year or Less) 620 $ 

Total Payables (Total lines 619 and 620) 621 $ 

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 622 $ 

Others 623 $ 

Total Current Maturities of Long-Term Debt (Total lines 622 and 623) 624 $ 

Other Current Liabilities 625 $ 

Total Current Liabilities (Total of Lines 618, 621, 624, and 625) 626 $ 

Other Liabilities: 

Long -Term Debt, Less Current Maturities: (Due after 1 year) 

Owners, Officers, and Related Entities 627 $ 

Others (Sources Not Related to Company) 628 $ 

Total Long-Term Debt, Less Current Maturities (Total lines 627 and 628) 629 $ 

TOTAL LIABILITIES (Total of lines 626, and 629) 630 $ 

EQUITY 

Owner's Equity (Unincorporated) 631 $ 

OR 

Stock Issued (Incorporated) 632 $ 

Additional Paid-in Capital 633 $ 

Retained Earnings 634 $ 

TOTAL EQUITY (total of lines 631 through 634) 635 $ 

TOTAL LIABILITIES AND EQUITY (Line 630 plus line 635) (should equal line 617) 636 $ 

 STATEMENT OF REVENUES AND EXPENSES - SECTION 7 

INCLUDE VALUES ONLY FOR REPORTING ENTITY. 

Net Sales (Gross sales less sales returns & allowances) 701 $ 

Cost of Sales 

Opening Inventory 702 $ 

Live Poultry Purchases 703 $ 

Poultry Grow-outs 704 $ 

Other Purchases 705 $ 

Subtotal (sum lines 702 through 705) 706 $ 

Closing Inventory 707 $ 

Total Cost of Sales (line 706 less 707) 708 $ 

Gross Profit (line 701 less 708) 709 $ 

Operating Expenses 

Manufacturing $ 710 

General, Sales, and Administrative 711 $ 

Depreciation & Amortization 712 $ 

Total Operating Expenses (sum lines 710 through 712) 713 $ 

Operating Income or Loss (line 709 less 713) 714 $ 

Adjustments to Operating Income 

Other Additions to Income $ 715 

Interest Expense (Enter as a negative number) 716 $ 

Other Deductions from Income (Enter as a negative number) 717 $ 

Adjustments to Operating Income + or - (Enter the sum total of lines 715 through 717; enter as + or -) 718 $ 

Net Profit or Loss (Add line 718 plus line 714) 719 $ 

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OMB Control No. 0581-0308 

CERTIFICATION - SECTION 8 

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 just be signed by a person listed in lines 201-205) 

801. Print Name: 802. Signature: 

803. Telephone: 804. Date: 805. 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 7 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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