PSD- 7003 Special Report For Review of Dealer, Market Agency & Pac

OMB Control No. 0581-0308
Business Entity ID Only

For PSD Use Only

U.S. Department of Agriculture
Agricultural Marketing Service
Fair Trade Practices Program
Packers and Stockyards Division

PSD Bar Code Only

SPECIAL REPORT FOR REVIEW OF DEALER,
MARKET AGENCY AND PACKER BONDS

Instructions: If an item's value is zero, enter "0". If an item does not apply, enter "NA". Upon completion please verify that all
items have been answered. Return completed form to the appropriate PSD regional office. See separate instructions for complete
information about this report. Only complete the section of this report that relates to your type of operation.
GENERAL INFORMATION - SECTION 1
101

Reporting Period
(mm/dd/yyyy)

a. FROM

b. TO

102 Entity Name
103 Trade Name/d.b.a.
104 Mailing Address
105 City, State, Zip+4
106 Operating Address
107 City, State, Zip+4
108 Contact Name
109 Contact Telephone

110 Fax Number

111 E-Mail Address

112 Web Address
BOND INFORMATION - SECTION 2
Note: Only complete the section that relates to your type of operation

Livestock Sold by a Market Agency:
201 Number of Public Sale Days that were held during this reporting period:
a. Cattle
202

Gross Value of all Livestock Sold on
Commission:

$

b. Hogs

c. Sheep & Goats

$

$

d. Horses & Mules
$

e. Total (a+b+c+d)
$

Livestock Purchased as a Dealer for their own account and on Commission for the accounts of others:
a. Cattle
b. Hogs
c. Sheep & Goats d. Horses & Mules
Cost of livestock purchased on a dealer
203
basis for registrant's account
$
$
$
$
Cost of livestock bought on commission
204 for the account of others regardless of
who paid for the livestock
$
$
$
$
a. First Quarter
b. Second Quarter
c. Third Quarter
Combined cost of livestock purchased as
205 a dealer, and bought on commission, per
quarter
$
$
$

e. Total (a+b+c+d)
$

$

d. Fourth Quarter

$

Livestock Purchased as a Packer:
206 Type of Livestock Purchased

Cattle

Calves

Hogs

207 Total Cost of Livestock Purchased for Feeding:

$

208 Total Cost of Livestock Purchased for Slaughter:

$

209 Total Livestock Purchased:

$

Form PSD 7003

Expires XX/XX/XXXX

Sheep/Goats

OMB Control No. 0581-0308

CERTIFICATION - SECTION 3
Under the Packers and Stockyards Act any person who willfully makes, or causes any false entry or statement of fact in this report shall be deemed guilty of offense against the
United States, and be subject to a fine of $1,000 to $5,000, or to imprisonment for a term of not more than 3 years, or to both fine and imprisonment.

With my signature, I certify the information provided on this form is true and correct to the best of my knowledge and belief, I am an owner, officer, or
have been authorized by responsible management to certify this report.
301 Print Name
303 Phone Number

302 Signature
304 Date

305 Title

Submitted information is confidential (9 CFR 201.96). Failure to report may result with a complaint filed against the entity in a United States District Court
charging the entity with violations of the Packers and Stockyards Act and seeking civil penalties as authorized by law, until report receipt. Section 10 of the
FTC Act made applicable by Section 402 of the Act (7 U.S.C. 222).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information is 0581-0308. The time required to complete this information collection is estimated to average 1.5
hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection.
In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating
on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all
programs.) 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 State or local Agency that administers the program 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 is also available in languages other than English.
To file a complaint alleging discrimination, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office or write a letter addressed to USDA and provided 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: (a) mail: U.S. Department
of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (b) fax: (202) 690-7442; or (c)
email: program.intake@usda.gov.

Form PSD 7003

Expires XX/XX/XXXX

Instructions to Complete Special Report for Review of
Dealer, Market Agency and Packer Bonds
Form PSD 7003
As an entity regulated by the Packers and Stockyards Act, you are required to file a special report with the
U.S. Department of Agriculture’s Packers and Stockyards Division (PSD) on Form PSD 7003 Special
Report for Review of Dealer, Market Agency and Packer Bonds.
Provide information for each line on the form that that applies to the period specified in the request letter.
If space provided for any item is not sufficient, attach additional pages containing the information and
make reference to the line number on the form
Submit the completed form by the date stated on the letter notifying you to file the special report, to the
PSD regional office that covers your area. The areas covered by each regional office are listed below its
address.
Failure to file this form may result with a complaint filed against the entity in a United States District
Court charging the entity with violations of the Packers and Stockyards Act and seeking civil penalties as
authorized by law, until report receipt. Section 10 of the FTC Act made applicable by Section 402 of the
Act (7 U.S.C. 222).
All information must be completed on this form in its entirety. Failure to do so will result in the
form being returned incomplete.
Regional Offices of the Packers and Stockyards Division
Agricultural Marketing Service, Fair Trade Practices Program
Eastern Regional Office
Midwestern Regional Office
Western Regional Office
75 Ted Turner Drive SW, Ste 230
210 Walnut Street, Room 317
3950 Lewiston St., Suite 200
Atlanta, GA 30303-3308
Des Moines, IA 50309-2110
Aurora, CO 80011-1556
Telephone: (404) 562-5840
Telephone: (515) 323-2579
Telephone: (303) 375-4240
FAX: (404) 562-5848
FAX: (515) 323-2590
FAX: (303) 371-4609
E-mail:
E-mail:
E-mail: PSDDenverCO@ams.usda.gov
PSDAtlantaGA@ams.usda.gov
PSDDesMoinesIA@ams.usda.gov
States Covered
States Covered
States Covered
AL, AR, CT, DC, DE, FL, GA,
IA, IL, IN, KY, MB, MI, MN,
AB, AK, AZ, BC, CA, CO, HI,
LA, MA, MD, ME, MS, NC,
MO, ND, NE, OH, ON, SD, WI
ID, KS, MT, NM, NV, OK, OR,
NH, NJ, NL, NY, PA, PR, QC,
SK, TX, UT, WA, WY
RI, SC, TN, VA, VT, WV

If you have any questions about the form or completing the form, please contact the PSD Regional Office that
covers your area, as listed above. Additional copies of the form may be obtained from the regional office, or on the
PSD website at https://www.ams.usda.gov/resources/forms

Form PSD 7003

Expires XX/XX/XXXX

SECTION-BY-SECTION INSTRUCTIONS
FORM HEADER – BUSINESS ENTITY ID
Business Entity ID should be completed using information on request letter. You may also contact the
appropriate regional office as listed above to obtain this information

Line No.
101
a and b
102
103
104
and
105
106
and
107
108
109
110
111
112
201
202
203
a
through
e
204
a
through
e

Subject

Instruction
GENERAL INFORMATION - SECTION
The reporting period covers the period of time specified in the
Reporting Period
request letter (FROM) [date], (TO) [date]. Please use the date
format MM/DD/YYYY
Enter the name under which you are registered with PSD.
Entity Name
Enter the trade name under which you operate. This is the
Trade Name/d.b.a.
name the business uses, if applicable. If you do not operate
with a “Trade Name/d.b.a,”, enter N/A.
Mailing Address
Enter your mailing address (street, city, state, and zip+4). This
is the address where all correspondence from PSD should be
sent.
Operating Address
Enter the physical location of your operating address (street,
city, state, and zip+4). This is the address where you conduct
your business services.
Contact Name
Enter the name of the person to be contacted regarding
questions on the annual report.
Contact Telephone
Enter the telephone where the contact person may be reached.
Fax
Enter the Fax used by the entity.
E-Mail Address
Enter the entity’s e-mail address.
Web Site Address (if
Enter the complete Web site address the business operates.
applicable)
For example: www.WebSiteName@domain.com
BOND INFORMATION – SECTION 2
Number of Public Sale
Enter the number of day’s livestock sales were conducted by
Days
the market.
Gross Value of Livestock
Enter the gross value of livestock sold on commission, for
each category of livestock, during the reporting period.
Cost of livestock
Enter the cost for each category of livestock, and the total cost
purchased as a dealer
of livestock purchased on a dealer basis during the reporting
period.
Cost of livestock bought
on commission

Form PSD 7003

Enter the cost for each category of livestock and the total cost
of livestock purchased as an order buyer during the reporting
period. You must include all livestock that you bought on
commission regardless whether you or another entity paid for
it.

Expires XX/XX/XXXX

Line No.
205
206
207
208
209
301
302
303
304
305

Subject
Combined cost of
livestock, per quarter

Instruction
Enter the combined cost of livestock purchased as a dealer,
and bought on commission, per quarter, during the reporting
period.
Type of Livestock
Check the appropriate box to indicate the type of livestock the
Purchased
entity purchased for slaughter and/or feeding, during the
reporting period.
Livestock Purchased for
Enter the gross dollar amount of all livestock purchased for
Feeding
feeding, during the reporting period.
Livestock Purchased for
Enter the gross dollar amount of all livestock purchased for
Slaughter
slaughter, during the reporting period.
Total Livestock Purchased Enter the sum total of lines 208 and 209.
CERTIFICATION – SECTION 3
Print Name
Print the name of the owner, officer, partner, or member
responsible for this report.
Signature
The report must be signed by a responsible person.
Phone Number
Enter the phone number of the person signing the report.
Date
Enter the date the report is signed.
Title
Enter the title of the person signing the report.

Form PSD 7003

Expires XX/XX/XXXX