Form 5200-17 Application for Fee Waiver Voluntary Bison Buffalo Inspe

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U. S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

Application for Fee Waiver: Voluntary Bison/Buffalo Inspection
at Establishments Owned by Native Americans or Operating on Tribal Lands
Purpose: The purpose of this form is to collect information to determine whether an establishment inspected by the Food Safety and Inspection Service (FSIS)
qualifies for free voluntary meat inspection for the slaughtering or processing of bison/buffalo at establishments owned by Native Americans or operating on
tribal lands.
The Agricultural Marketing Act (AMA) provides the Secretary of Agriculture with the authority to prescribe rules for the inspection and certification of products in
interstate commerce and to collect fees to cover the cost of the service rendered so agricultural products may be marketed to the best advantage, to facilitate
trade, and so consumers may be able to obtain the quality product which they desire (7 U.S.C. 1622(h)). FSIS has developed regulations to perform voluntary
and other reimbursable services based on this authority to inspect, certify, and identify the class, quality, quantity, and condition of agricultural products when
shipped or received in interstate commerce at warehouses and official establishments. Congress has provided FSIS with funds to cover voluntary inspection
fees for the slaughtering or processing of bison/buffalo at establishments owned by Native Americans or establishments operating on tribal lands (Consolidated
Appropriations Act, 2024 [Pub. L. 118-42, 138 Stat. 115]).
Definitions: For the purposes of this form, terms are defined as follows:
“Voluntary inspection” is FSIS inspection of exotic animals (including bison/buffalo) for wholesomeness as a voluntary service described in 9 CFR part 352.
“Bison/Buffalo” refers to any species of the genus Bison native to North America, commonly known as the American bison/buffalo, as defined in 9 CFR 352.1(e).
“Establishment owned by Native Americans” means “a USDA inspected food processing establishment that is owned by an Indian Tribe as defined by the
Federally Recognized Indian Tribe List Act of 1994 (25 U.S.C. 5130) or an enrolled member of an Indian Tribe.”
Please provide below the Name, Title, Work phone, E-mail address, and Work address of person signing the form.
1. Name: (First, Last)

2. Title:

5. Work Address:

3. Work Phone: (1234567890)

4. E-mail: (Firstname.last@usda.gov)

6. City:

7. State:

8. Zip Code:

10. Date: (mm/dd/yyyy)

9. Signature:

Provide the Establishment number and address of establishment applying for free voluntary bison/buffalo inspection. (Establishment information is available in
the FSIS Inspected Establishment Listings at: https://www.fsis.usda.gov/inspection/fsis-inspected-establishments.)
11. Establishment Number:
13. City:

12. Establishment Address:

14. State:

15. Zip Code:

ADDITIONAL QUESTIONS
16. How many hours of voluntary inspection did the establishment receive for
the slaughter or processing of bison/buffalo since October 1, 2023?

Total Hours:

17. How many head of bison/buffalo has the establishment slaughtered since
October 1, 2023?

Head Slaughtered:

18. How many pounds of bison/buffalo meat has the establishment processed
since October 1, 2023?

Pounds Processed:

ATTESTATION
19. Check all that apply:
A. I, attest that the above-named establishment is owned by an Indian Tribe (or its wholly owned arm or instrumentality) as defined by the Federally
Recognized Indian Tribe List Act of 1994 (25 U.S.C. 5130) or an enrolled member of an Indian Tribe and that it slaughters or processes bison/buffalo.
B. I, attest that the above-named establishment operates on tribal lands.

Persons making false, fictitious, or fraudulent statements or entries are subject to a $10,000.00 fine or imprisonment
for not more than 5 years or both, as prescribed by 18 U.S.C §1001.
FSIS 5200-17 (06/05/2024)

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