Form LP-85 Lamb Feeder Checkoff Refund

OMB No. 0581-NEW

AMERICAN LAMB BOARD

LAMB FEEDER CHECKOFF REFUND

PLEASE READ THE INSTRUCTIONS ON THE REVERSE SIDE OF APPLICATION

BEFORE COMPLETION (PLEASE TYPE OR PRINT)

Name of Applicant	Telephone No. (include area code)
Name of Business
Business Address City State Zip

Companies that collected Lamb Checkoff assessment:

Auction/Sale Barn
First Handler/Packer
Number of Sheep Assessed		Date
Total Lamb Checkoff assessment paid at auction/sales barn
Total weight assessed by first handler/packer buyers that you are not responsible for

Total Refund Requested: _____________________

I certify that I have paid a portion of the lamb checkoff assessment for which I am not responsible for as a feeder. I am now seeking a refund. The information contained in this request is correct and not false or fraudulent. I have not previously submitted a similar request on these same sheep. I am signing this refund either as the applicant or as an authorized representative on behalf of the applicant.^1/

____________________________________________ ___________________________________

Name of Applicant (Print) Title

____________________________________________ ___________________________________

Signature of Applicant or Authorized Representative Date

1/ The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18,§1001 United States Code, which provides for the penalty of a fine of $10,000, imprisonment of not more than 5 years, or both.

INSTRUCTIONS

1. This application form must be received in the American Lamb Board office no later than 60 days following date of sale.

1. American Lamb Board

Address

City, State, Zip

2. A copy of the Bill of Sale establishing that the assessment has been paid by you must be submitted with the refund form.

3. A refund will be paid within 30 days of receipt of the completed form as either an electronic payment or check.

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-NEW. The time required to complete this information collection is estimated to average 15 minutes/hours 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.

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.

LP-85 (Expiration Date XX/XX/20XX) Page 1 of 2