Form QSBC-1 Producer Redirection of Checkoff assessments Form

Form QSBC-1 [QSBC NAME] Approval: OMB 0581-NEW

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 state beef councils to retain 50 cents per head of the mandatory $1-per-head checkoff assessment for in-State research and promotion programs conducted by the state beef council. The law requires that at least 50 cents per head 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. [State] 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. Mail forms to the [QSBC Name], at [QSBC address]. PRODUCER REDIRECTION OF CHECKOFF ASSESSMENTS FOR ALL CATTLE MARKETED IN THE MONTH OF: ______________, 20_____

Company:

Requested by:

Address:

City:

State:

Zip Code:

Phone Number:

Email:

Please attach a copy of the livestock-market invoice or other 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

1/15/2016

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.

______________________________________________________________________________________________________________

DATE RESPONDING OFFICIAL’S NAME (PRINT)

______________________________________________________________________________________________________________

TITLE (PRINT) SIGNATURE

[QSBC Name] use only
[QSBC NAME] Approval for Processing:
Amount to be Redirected to the Cattlemen’s Beef Promotion and Research Board: $
	Signature		Date

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