WA-105 Returned and Destroyed Receipt Record

Form Approved - OMB No. 0560-0120

This form is available electronically. See Page 2 for Privacy Act and Paperwork Reduction Act Statements.

WA-105 U.S. DEPARTMENT OF AGRICULTURE (10-31-11) Farm Service Agency RETURNED AND DESTROYED RECEIPT RECORD

1. NAME AND ADDRESS OF WAREHOUSE OPERATOR

2. NAME AND LOCATION OF WAREHOUSE

3. LICENSE NO.

     

     

     

PART A - RECEIPTS

RECEIVED

7. BY WHOM

DESTROYED

RETURNED TO WAREHOUSE OPERATOR

4. DATE (MM-DD-YYYY)

NUMBERED

8. DATE (MM-DD-YYYY)

9. BY WHOM

10. DATE (MM-DD-YYYY)

11. BY WHOM

12. RECEIVED BY

5. FROM

6. TO

     

     

     

     

     

     

     

     

     

     

     

     

     

   

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART B – LICENSES

RECEIVED

16. BY WHOM

RETURNED TO KCCO

RETURNED TO WAREHOUSE OPERATOR

13. DATE (MM-DD-YYYY)

NUMBERED

17. DATE (MM-DD-YYYY)

18. BY WHOM

19. DATE (MM-DD-YYYY)

20. BY WHOM

21. RECEIVED BY

14. LICENSE NO.

15. NAME

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

22. REMARKS

     

23. I authorize destruction of the above forms.

A. SIGNATURE OF AUTHORIZED OFFICER OR MANAGER

B. DATE (MM-DD-YYYY)

C. SIGNATURE OF WAREHOUSE EXAMINER

D. DATE (MM-DD-YYYY

     

     

WA-105 (10-31-11) (Page 2)

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 735, 7 CFR Part 1423, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.).  The information will be used to develop a record of returned and destroyed warehouse receipts and warehouse licenses. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act. 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 an OMB control number. The valid OMB control number of this information collection is 0560-0120. The time required to complete this information collection is estimated to average 15 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.