QSSB-1 Producer Redirection of Checkoff Assessments Form

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

Producer Redirection of Checkoff Assessments Form

The Soybean Promotion, Research, and Consumer Information Act and Order require collection of a mandatory 0.5 percent of the net market price per bushel checkoff assessment every time soybeans are sold. The Act and Order authorize State soybean councils to retain 50 percent of the mandatory checkoff assessment for in-State research and promotion programs conducted by the State soybean boards. The Act requires that half of the mandatory checkoff assessment be forwarded to the United Soybean Board (Soybean Board) to help fund national soybean checkoff programs. [State] producers may use this form to request that the [QSSB] send the full 0.5 percent of the net market price per bushel checkoff assessment from their individual soybean sales to the Soybean Board and that the [QSSB] 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 30th of the month following the month the soybeans were sold. Mail forms to the [QSSB Name], at [QSSB address]. PRODUCER REDIRECTION OF CHECKOFF ASSESSMENTS FOR ALL SOYBEANS MARKETED IN THE MONTH OF: ______________, 20_____

Company:

Requested by:

Address:

City:

State:

Zip Code:

Phone Number:

Email:

Please attach a copy of the market invoice or other documents supporting payment of the soybean checkoff assessment as required verification of each transaction listed below.

Name of First Purchaser that collected the Soybean Checkoff Assessment

Date of Sale

Total Number of Bushels Assessed

Requested Redirection of State Portion of Checkoff Assessments to the Soybean Board (0.5 % of net market price per bushels sold)

Example: ABC Elevator

1/15/2016

1,000

$60.00 (0.5 % of net market price per bushels sold)

Total amount requested for redirection to the Soybean 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

[QSSB Name] use only
[QSSB NAME] Approval for Processing:
Amount to be Redirected to the United Soybean Board: $
	Signature		Date

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