Form 7001 – Fill Out and Use This PDF

101Date of Report (mm/dd/yy)

102Legal Business Name

103Business Name (dba)

104Mailing Address

105City, State, Zip

106Physical Address

107City, State, Zip

108Contact Name

109Telephone Number

110Fax Number

CUSTODIAL ACCOUNT INFORMATION - SECTION 2

CUSTODIAL ACCOUNT DESIGNATION - SECTION 3

ANALYSIS OF CUSTODIAL BANK ACCOUNT FOR SHIPPERS' PROCEEDS - SECTION 4

OMB No. 0580-0015

PROCEEDS RECEIVABLE - SECTION 5

“Proceeds Receivables” vary based on the livestock buyer. For most buyers when conducting the custodial analysis any uncollected funds during the time period including the analysis date and the 6 days before the analysis are proceeds receivables. For livestock purchases made by the market, its owner, officers, employers, and credit buyers the time period is limited to include only the analysis date and the previous business day.

CERTIFICATION - SECTION 6

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.

I certify that this report has been prepared by me or under my direction, and to the best of my knowledge and belief correctly reflects reporting entity operations.

Submitted information is confidential (9 CFR 201.96). Failure to report will result in forfeiture to the United States $110 per day until report receipt 7 (U.S.C. 222). Response is required in order to determine establishment, maintenance and status of custodial account (9 CFR 201.97). 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 is 0580-0015. The time required to complete this information collection is estimated to average 3 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.

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 and employer.