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OMB No. 0581-0093 

Beef Checkoff Program 

Producer Redirection of Checkoff Assessments Form 

The Beef Promotion and Research Act and Order require collection of a mandatory $1-per-head beef checkoff assessment every time cattle are sold. The 

Act and Order authorize qualified State beef councils (QSBC) to retain up to 50 cents per head of the mandatory $1-per-head checkoff assessment for inState research and promotion programs conducted by the State beef council. The law requires that at least 50 cents of the mandatory $1-per-head checkoff 

assessment be forwarded to the Cattlemen’s Beef Promotion and Research Board (Beef Board) to help fund national beef checkoff programs. Producers 

may use this form to request that the QSBC send the full $1-per-head beef checkoff assessment from their individual cattle sales to the Beef Board and that 

the QSBC not retain any portion of the individual’s assessment for its direct programing efforts. 

This “Producer Redirection of Checkoff Assessment Form” must be postmarked by the 15th of the month following 

the month the cattle were sold and mailed to the appropriate QSBC. 

PRODUCER REDIRECTION OF CHECKOFF ASSESSMENTS FOR ALL CATTLE 

MARKETED IN THE MONTH OF: , 20 

Company: ________________________________________ Requested by: ______________________________________________ 

Address: __________________________________________________________________________________________________________ 

City: _____________________________________________ State: ___________________ Zip Code: ______________________________ 

Phone No.: ____________________________________________ Email: ___________________________________________________ 

Please attach a copy of documents supporting payment of the beef checkoff assessment 

as required verification of each transaction listed below. 

Name of Collecting Point that 

collected the Beef Checkoff 

Assessment Date of Sale 

Total Number of Head 

Assessed 

Requested Redirection of State Portion of 

Checkoff Assessments to the Beef Board 

($0.50/head) 

Example: ABC Livestock Market 1/15/2020 20 $10.00 ($0.50 per head) 

Total amount requested for redirection to the Beef Board 

I declare under the penalties provided by law, that this “Producer Redirection of Checkoff Assessments Form” has been examined 

by me and, to the best of my knowledge, is true, correct and complete. I also certify that I am authorized to sign this form. 

RESPONDING OFFICIAL’S NAME (PRINT) DATE 

TITLE (PRINT) SIGNATURE 

QSBC-1 (Expiration Date 11/30/2024) Page 1 of 2 See reverse for burden/non-discrimination statement 

OMB No. 0581-0093 

[QSBC Name] use only 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[QSBC NAME] Approval for Processing: 

Amount to be redirected to the Beef Board: $ 

Signature Date 

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 collection is 0581-0093. The time required to 

complete this information collection is estimated to average 5 minutes 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 civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, 

and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, 

religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a 

public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not 

all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. 

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 Agency 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 may be made available in languages other than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at 

http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide 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: (1) mail: 

U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: 

(202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender. 

QSBC-1 (Expiration Date 11/30/2024) Page 2 of 2