FGIS-941 Request for Waiver of Inspection

This is a fillable form; fill out, print, sign original, and mail to service area GIPSA Field Office.
FORM APPROVED OMB NO. 0580-0013 (FGIS-941)
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 0580-0013. The
time required to complete this information collection is estimated to average 5 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 information.

U.S. DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND STOCKYARDS ADMINISTRATION
FEDERAL GRAIN INSPECTION SERVICE
REQUEST FOR WAIVER OF INSPECTION
TO:

FROM:

We hereby request a waiver of inspection for the lot identified below. (An English written copy of the contract is attached.)

NAME OF VESSEL

CONTRACT NO.

LOCATION OF SERVICE

DESTINATION

APPROXIMATE DATE OF LOADING

KIND OF GRAIN

QUANTITY OF GRAIN TO BE LOADED

CONTAINER MARKING

____

______________
(DATE)

____

____

___________________________________________________
(NAME AND SIGNATURE)
____________________________________________________
(TITLE)

FOR USDA USE ONLY

QUANTITY OF GRAIN LOADED

WAIVER APPROVED

WAIVER DENIED FOR THE FOLLOWING REASON(S): _____________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________

__________________
(DATE)

______________________________________________________________
(NAME AND SIGNATURE)

FIELD OFFICE MANAGER
(TITLE)
FORM FGIS-941 07/04 Expires January 2015

FORM APPROVED OMB NO. 0580-0013 (FGIS-941)
According to the Paperwork Reduction Act of 1995, no persons are 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 0580-0013. The time required to complete this information
collection is estimated to average 5 minutes per response and 1 minute of recordkeeping,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.

U.S. DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND STOCKYARDS ADMINISTRATION
FEDERAL GRAIN INSPECTION SERVICE
REQUEST FOR WAIVER OF INSPECTION

1.

TO:

2.

FROM:

We hereby request a waiver of inspection for the lot identified below. (An English written copy of the contract is attached.)

NAME OF VESSEL

CONTRACT NO.

3.
5.
7.

4.

LOCATION OF SERVICE

DESTINATION

6.

APPROXIMATE DATE OF LOADING

KIND OF GRAIN

QUANTITY OF GRAIN TO BE LOADED

8.

9.

CONTAINER MARKING

10.

11.
____

______________
(DATE)

____

____

12.

___________________________________________________
(NAME AND SIGNATURE)

13.

____________________________________________________
(TITLE)

FOR USDA USE ONLY

14.

QUANTITY OF GRAIN LOADED

WAIVER APPROVED

15.

WAIVER DENIED FOR THE FOLLOWING REASON(S): _____________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________

16.

__________________
(DATE)

17. ______________________________________________________________
(NAME AND SIGNATURE)

FIELD OFFICE MANAGER
(TITLE)
FORM FGIS-941 07/04

INSTRUCTION FOR COMPLETING “REQUEST FOR WAIVER OF INSPECTION”
FORM FGIS-941
1.

Show the name of person who the letter is addressed to.

2.

Show the name of the person who is requesting the waiver.

3.

Show the name of the vessel for which the waiver of inspection is requested.

4.

Show the contract number for the lot of grain which the waiver is requested.

5.

Show the location of the elevator where the grain is to be loaded.

6.

Show the country of destination of the grain to be loaded.

7.

Show the approximate date the grain will be loaded.

8.

Show the type of grain to be loaded.

9.

Show the approximate quantity of grain to be loaded.

10.

Show any applicable markings of the containers.

11.

Show the date of the applicant’s signature.

12.

Show the name and signature of the applicant for the wavier of inspection.

13.

Show the title of the person signing the wavier of inspection.

14.

Show the actual quantity of grain that was loaded.

15.

Check the appropriate box. If the wavier is denied please include the reason(s) for denial.

16.

Show the date of the Field Office Manager’s signature.

17.

Show the name and signature of the Field Office Manager.

CONTACT INFORMATION:
Contact the field office responsible for the geographic area in which the service will be provided.
Details for these locations can be found at:
http://www.gipsa.usda.gov/GIPSA/webapp?area=home&subject=fc&topic=fsp
The signed form should also be mailed to this location.
For further information on Request for Waiver of Inspection:
Robert S. Lijewski, Director
Field Management Division
1400 Independence Avenue, SW, Room 2409 N
Washington, DC 20250-3630
Telephone:
Fax:
Email:

(202) 720-0228
(202) 720-1015
robert.s.lijewski@usda.gov