Form QSBC-1 Producer Redirection of Checkoff assessments Form

Approval: OMB 0581-0294

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 up
to 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 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 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:

Phone Number:

Email:

Zip Code:

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
Example: ABC Livestock Market

Date of Sale

Total Number of Head
Assessed

Requested Redirection of State Portion of
Checkoff Assessments to the Beef Board
($0.50/head)

1/15/2019

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 Beef Board:

Signature

QSBC-1 (Expiration Date 11/2022)

$

Date

See reverse for burden/non-discrimination statement

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