Submit the original of the completed form in hard copy or facsimile to the Kansas City Commodity Office (KCCO), Warehouse License and Examination Division, STOP 9148, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 816-926-1548. Customers who have established electronic access credentials with KCCO may electronically transmit this form to KCCO. Features for transmitting the form electronically are available to those customers who would like to establish online access credentials with KCCO, follow the instructions provided at the USDA eforms web site.
Fld Name / |
Instruction |
A Name of Provider |
Enter complete name of Provider, on page 1. |
(a) Name of Provider |
Enter complete name of Provider, on page 4. |
(b) Signature |
Enter signature of Provider’s authorized person, on page 4. |
(c) Title |
Enter title of Provider’s authorized person, on page 4. |
(d) Date |
Enter date of signature of Provider’s authorized person, on page 4. |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Ball, MaryAnn - FSA, Washington, DC |
File Modified | 0000-00-00 |
File Created | 2021-01-28 |