Transcription of COUNTRY OF ORIGIN AFFIDAVIT/DECLARATION
1 307-399-9863 307-340-0150 307-340-0770 307-575-4015 307-745-5012 307-334-3388 307-532-0121 Jeff Ward Cody Thompson Ty Thompson Chuck Petersen Shawn Madden Lex Madden Michael Schmitt 307-532-7518 307-532-4985 308-247-3193 307-532-1575 307-532-1580 307-532-1776 Box 1097 * 626 West Valley Rd * Torrington, WY 82240 307-532-3333 * 307-532-4111 * Fax 307-532-2040 COUNTRY OF ORIGIN AFFIDAVIT/DECLARATION As an affidavit is deemed by the United States Department of Agriculture as an official record of COUNTRY of ORIGIN . I attest through first-hand knowledge, normal business records, or producer affidavit(s) that all live-stock referenced by this document or other communications specific to the transaction and transferred are of _____( COUNTRY ) ORIGIN .
2 Should the ORIGIN of my livestock become other than that described above, I agree to notify the agent when this occurs. I attest that _____(insert business name) has and will maintain records of livestock ORIGIN for one year from the date of delivery of the livestock . I attest that these records reflecting specific transactions are available for inspection for the sole purpose of compliance with an audit as described by the COUNTRY -of- ORIGIN labeling provisions contained in the Farm Security and Rural Investment Act of 2002 as amended. ( 108-767, USCA section 1638a, 2003). This continuous AFFIDAVIT/DECLARATION of COUNTRY of ORIGIN of Livestock shall remain in effect until revoked in writing by the undersigned producer.
3 _____ Business/Farm/Ranch Names - Address State Zip _____ Telephone _____ Signature _____ Print Name Date
