Form Accounts Payable I Accounts Payable I LP-109A

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.

U.S. DEPARTMENT OF AGRICULTURE

OMB APPROVED: NO. 0581-XXXX

AGRICULTURAL MARKETING SERVICE
Livestock and Poultry Program
Quality Assessment Division

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-XXXX. The time required to
complete this information collection is estimated to average 5 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.

ACCOUNTS PAYABLE
INFORMATION REQUEST

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on
the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial
status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or
because all or part of an individual's income is derived from any public assistance program. (Not all
prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA's
TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA,
Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call
(800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider, employer, and
lender.

Submit Completed Form to:
(Choose one option)

USDA, MRP, AMS, L&P, QAD
Business Operations Branch
10809 Executive Center Drive, Suite 318
Little Rock, AR 72211-6022

Email:
Telephone:
Fax:

QAD.BusinessOps@usda.gov
501-312-2962
1-844-345-3575

APPLICANT INFORMATION
Check One:

New Customer

Revision to Applicant Account #: _______________________________

NAME OF APPLICANT (As shown on your income tax return):
DOING BUSINESS AS (If applicable):

Tax ID Number:
This is the Corporate Tax ID number unless the entity submitting the application is an individual, then the Social Security Number is required. (Required by IRS).

ACCOUNTS PAYABLE DEPARTMENT MAILING ADDRESS:
(Street and NO. or P.O. Box; City, State, and ZIP Code + 4)

Accounts Payable Contact:
Accounts Payable Phone Number:
Accounts Payable Email:
Accounts Payable Fax:
Remarks:

FOR OFFICIAL USE ONLY
DATE RECEIVED:

LP-109A (XX/20XX)

RECEIVED BY:

EXP. DATE: XX/XX/XXXX