LPS-25 Application for Certification of Organization or Associa

REPRODUCE LOCALLY. Include form number on all reproductions.

FORM APPROVED. - OMB NO. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

APPLICATION FOR CERTIFICATION OF ORGANIZATION OR ASSOCIATION
Organizations or associations must apply for certification by the Secretary to be eligible to participate in the making of
nominations of cattle producers to serve as members of the Cattlemen's Beef Promotion and Research Board as provided in
the Beef Promotion and Research Act of 1985. Information submitted in response to all items must be complete. Please type or
print clearly. Send form to:

Research and Promotion Division
Livestock, Poultry, and Seed Program, AMS
U.S. Department of Agriculture
Street
City, State Zip
FAX: (202) 720-1125

2. TYPE OF ORGANIZATION
(Please check one)

1. NAME AND ADDRESS OF ORGANIZATION (Street address or P.O. Box No., City, State, ZIP)

STATE CATTLE ASSOCIATION
STATE GENERAL FARM
FACSIMILE NO. AND AREA CODE

TELEPHONE NO. AND AREA CODE

3. STATE

OTHER

5. TOTAL ESTIMATED INVENTORY OF
CATTLE OWNED BY PAID MEMBERS (Most
RECENT FULL calendar year)

4. NUMBER OF PAID MEMBERS ENGAGED IN CATTLE PRODUCTION
(Most RECENT FULL calendar year)

AS OF JAN. 1, 20

NO.

6. AS EVIDENCE OF THE STABILITY AND PERMANENCY OF THE ORGANIZATION, GIVE:
A. No. of years in existence

B. No. of paid members engaged in cattle production during each of the last four calendar years:

20

20

20

20

C. Other Evidence (Explain)

I hereby certify that: (1) a primary or overriding purpose of this organization or association is to promote the economic welfare of cattle
producers, and (2) the information provided in response to the above items is true, complete, and correct to the best of my knowledge.
The Secretary of Agriculture may examine our books, documents, papers, records, files, and facilities to verify any of the information
submitted and may procure such other information as may be required to determine this organization's or association's eligibility for
certification.
7. NAME AND TITLE OF PERSON COMPLETING THE APPLICATION
(Type or print)

8. EMAIL ADDRESS (name@provider.com)

LPS-25 (rev. 04-2017)

9. SIGNATURE

10. DATE

See reverse for burden/non-discrimination statement

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 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintain the data needed, and completing and review 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.