Form P&SP2120 "Proof of Claim Under Surety Bond - Clause No. 2, 3, & 4"

What Is Form P&SP2120?

This is a legal form that was released by the U.S. Department of Agriculture and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download Form P&SP2120 "Proof of Claim Under Surety Bond - Clause No. 2, 3, & 4"

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OMB CONTROL NO. 0580-0015
U.S. Department of Agriculture
Proof of Claim Under:
Grain Inspection, Packers and
1. Surety Bond, (Clause 2, 3, or 4)
Stockyards Administration
2. Trust Fund Agreement, (Clause 2, 3, or 4)
Packers and Stockyards
3. Trust Agreement, (Clause 2, 3, or 4)
Program
Issued Under Provisions of The Packers and
Stockyards Act, 1921, as Amended and Supplemented
State of (1) ________________________________________
County (2) ________________________________________
As the undersigned, I, (3) ___________________________________________________
(
full name of claimant)
Of (4) __________________________________ (5) _____________________________
(
)
(
)
complete mailing address
phone: home, cell
________________________________________________________________________
(
)
other contact information: fax number, email address
being duly sworn, depose and state:
I make this claim to (6) ____________________________________________________
(
)
name of trustee or surety
Select One:
under the bond issued by the (7a)
___________________________________________________________
(
)
name of surety company
under the Trust Fund Agreement with security held by (7b)
____________________________________________________________
(
)
depository, if one named
under the Trust Agreement with letter of credit held by (7c)
____________________________________________________________
(
)
name of trustee
on behalf of (8) ___________________________________________________________
(
)
full name and address of principle named in bond or trust agreement
________________________________________________________________________
in the amount of (9) ___________, due and owing for livestock purchased by
(10) _________________________________________________
(full name and address of buyer) Clause 2, 3, or 4
for his own account or as a market agency buying livestock on a commission basis. This
Form P&SP 2120
Expires 11-30-2017
Page 1 of 3
OMB CONTROL NO. 0580-0015
U.S. Department of Agriculture
Proof of Claim Under:
Grain Inspection, Packers and
1. Surety Bond, (Clause 2, 3, or 4)
Stockyards Administration
2. Trust Fund Agreement, (Clause 2, 3, or 4)
Packers and Stockyards
3. Trust Agreement, (Clause 2, 3, or 4)
Program
Issued Under Provisions of The Packers and
Stockyards Act, 1921, as Amended and Supplemented
State of (1) ________________________________________
County (2) ________________________________________
As the undersigned, I, (3) ___________________________________________________
(
full name of claimant)
Of (4) __________________________________ (5) _____________________________
(
)
(
)
complete mailing address
phone: home, cell
________________________________________________________________________
(
)
other contact information: fax number, email address
being duly sworn, depose and state:
I make this claim to (6) ____________________________________________________
(
)
name of trustee or surety
Select One:
under the bond issued by the (7a)
___________________________________________________________
(
)
name of surety company
under the Trust Fund Agreement with security held by (7b)
____________________________________________________________
(
)
depository, if one named
under the Trust Agreement with letter of credit held by (7c)
____________________________________________________________
(
)
name of trustee
on behalf of (8) ___________________________________________________________
(
)
full name and address of principle named in bond or trust agreement
________________________________________________________________________
in the amount of (9) ___________, due and owing for livestock purchased by
(10) _________________________________________________
(full name and address of buyer) Clause 2, 3, or 4
for his own account or as a market agency buying livestock on a commission basis. This
Form P&SP 2120
Expires 11-30-2017
Page 1 of 3
OMB CONTROL NO. 0580-0015
claim is based on the following described livestock which was purchased by
(11) ______________________________________________________________
(name of buyer) Clause 2, 3, or 4
(12)
Date of Sale
Number of Head
Description of Livestock
Amount
$
Attached and made a part of this claim are copies of the account of purchase and other
documents covering the livestock transaction, such as copies of checks issued and unpaid
for the livestock purchased by:
(13)______________________________________________________________
(name of buyer) Clause 2, 3, or 4
and other documents indicating the sale of the livestock in question to such purchaser
for which payment has not been made. (
If full and complete documents of the transaction are not
available or if these papers have become lost or destroyed, the claimant should insert a statement below of
:)
the facts
(14)____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Form P&SP 2120
Expires 11-30-2017
Page 2 of 3
OMB CONTROL NO. 0580-0015
None of the claimed amounts has been paid, and there are no setoffs or counterclaims to
the same.
I hereby authorize the Grain Inspection, Packers and Stockyards Administration, Packers
and Stockyards Program to release this proof of claim form and all of the attached
supporting documents to the trustee or other interested parties to facilitate the processing
of my claim.
(15) _____________________________________
(
)
signature and title of claimant
(16) Subscribed and sworn to before me this _____ day of ______, 20_____.
(17) _____________________________________
(18) Notary Public for the State of _____________
(19) Residing at ____________________________
My commission expires
(20) _________________________ (
)
seal
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 0580-0015. The time
required to complete this information collection is estimated to average 1 hour 30 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 informaiton.
s
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.
Form P&SP 2120
Expires 11-30-2017
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