LP-46-1 Soybean Report & Remittance (Alternative Form)--Amount C

OMB NO. 0581-0093

ALTERNATIVE FORM: To be used by first time purchasers with computerized recordkeeping systems that cannot supply information required on primary remittance form. Columns A, B, C, and D must be completed in detail.

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SOYBEAN PROMOTION, RESEARCH, AND CONSUMER INFORMATION PROGRAM (SPARC)

A program of promotion, research, and consumer information designed to strengthen, expand and develop new foreign and domestic markets for soybeans and soybean products.

Note: Information is required by 7 CFR 1220.223. Failure to report can result in a fine. Information is held confidential (7 CFR 1220.243).

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 1 hour 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.

_{REPORT AND REMITTANCE OF AMOUNT COLLECTED AND DUE ON SOYBEANS PURCHASED}

NAME AND ADDRESS (include P.O. Box or Street, City, State, and ZIP)			Federal Identification Number
			State Grain Dealer License Number (if applicable)
			County
			Business Telephone (include area code)
The report and assessments must be remitted (postmarked) by the last day of the month following the end of the collection period. Late Payments are subject to a 2 percent per month late payment charge. Must be remitted by . The following report is a report on soybeans purchased and the net market value paid for such purchases for the period commencing and ending .				“Net market value” (quoted price plus or minus premiums or discounts such as moisture and quality factors) is the total dollars paid for assessed soybeans during the reporting period.
(A)	(B) STATE OF ORIGIN	(C) NET MARKET VALUE OF ASSESSED BU.		(D)
				RATE	TOTAL
NUMBER OF BUSHELS PURCHASED (ALL STATES) BUSHELS				X.005 =	$
				X.005 =	$
				X.005 =	$
NET MARKET VALUE OF ALL BUSHELS PURCHASED (ALL STATES) $				X.005 =	$
				X.005 =	$
	* NOTE: If remitting assessments past due date, calculate the 2 percent mandatory late payment (compounded monthly). Total Assessments x.02 = Late Payment			TOTAL ASSESSMENTS =
				* LATE PAYMENT =
SEND THIS REPORT AND A CHECK IN THE TOTAL AMOUNT SHOWN ABOVE TO:				TOTAL REMITTANCE =
				OFFICE USE ONLY
				PENALTIES: You may, by law, be fined up to $10,000, imprisoned up to 5 years, or both for knowingly or willfully making false statements within this document (18 U.S.C. §1001).
CERTIFICATION STATEMENT

I declare, under the penalties provided by law, that this report has been examined by me; and to the best of my knowledge and believe is a true, correct and complete report.

_{NAME/TITLE (Print or type) SIGNATURE DATE}

LP-46-1 (Expiration Date XX/XX/XXXX) See reverse for burden/non-discrimination statement

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-46-1 (Expiration Date XX/XX/XXXX)