Free 51025.pdf - Indiana

LIVESTOCK DEALER BUSINESS REPORT
State Form 51025 (R / 10-08)

INDIANA STATE BOARD OF ANIMAL HEALTH

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INDIANA STATE BOARD OF ANIMAL HEALTH ATTENTION: LICENSING 805 Beachway Drive, Suite 50 Indianapolis, IN 46224

Under IC 15-17-14 and 345 IAC 7-3.5 a person holding a livestock dealer license must submit to the state veterinarian a completed copy of this annual report of the licensee's livestock dealing. A livestock dealer that is registered with the United States Department of Agriculture Grain Inspection, Packers and Stockyards Administration (USDA P&S), may submit a copy of their most recent USDA P&S report in lieu of this annual report form. A licensee's annual report must be submitted to the state veterinarian between January 1 and April 15 of each year and must cover the prior years business. Return completed report to the address above. CERTIFICATION I certify that the following report has been prepared by me or under my direction, and that to the best of my knowledge and belief, said report correctly reflects the operations of the reporting firm.
Signature of Owner, Partner, or Responsible Officer, if a business entity This report is for business conducted in the following time period: Title Date (month, day, year)

GENERAL INFORMATION
Name Under Which Business is Conducted (Name that is on the Dealer License) Address (number and street, city and state): Telephone Number: ZIP code

Type of Organization:

Individual

Partnership

Corporation

Limited Liability Corp.

Other:

Yes Did the organization change during the year? reported. Attach a separate sheet if necessary):

No If yes, give details (Include any changes in managers or agents not previously

BOND INFORMATION For the period covered by this report
1. 2. Total cost of livestock purchased on a dealer basis (or as a packer) for your account: $ Total cost of livestock purchased for the account of others (Include livestock you purchased but that was billed direct to customer by seller and paid for by customer to seller.): $ Total gross value of livestock sold on commission: $

3.

LIVESTOCK PURCHASES For the period covered by this report
Number of Head Purchased by This Dealer: Number of Head Consigned by Others to Dealer's Firm for Sale: Hogs Cattle Equine Sheep/Goats Deer/Elk All Other

Hogs

Cattle

Equine

Sheep/Goats

Deer/Elk

All Other