Warehouse Regulations Under the United States Warehouse Act

Instructions For WA-139

CERTIFICATE OF LOSS OF CANCELED OR UNCANCELED WAREHOUSE RECEIPT(S)

This form is used by warehouse operators to certify, under oath, warehouse-operator lost paper warehouse receipts, either canceled (indemnifying third parties who might be injured by the use of a canceled paper warehouse receipt) or not canceled (indemnifying third parties who may inadvertently be injured by use of a duplicate paper warehouse receipt), and to indemnify third parties who might be injured by use of the lost warehouse receipts.

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 816-926-1774.

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.

Warehouse Operators prepare the form, return the original to KCCO and retain a copy in their warehouse receipt book in place of the warehouse receipt that was lost.

Warehouse Operator completes all items except 19B and 19C.

Items 19B and 19C will be completed by the Depositor or Owner receiving replacement paper warehouse receipt(s).

Items 1-19C

Fld Name /Item No.	Instruction
1 Type of Warehouse Receipt(s)	Check boxes whether canceled or not canceled warehouse receipt and whether negotiable or not negotiable warehouse receipt.
2 License Number	Enter United States Warehouse Act (USWA) license number. (Likely pre-printed on the unused paper warehouse receipt.)
3 Name of Warehouse	Enter complete name of the licensed warehouse, for example, “Doe Brothers Warehouse.” (Likely pre-printed on the unused paper warehouse receipt.)
4 Warehouse Location	Enter the city and State of the principal location of the warehouse license. (Likely pre-printed on the unused paper warehouse receipt.)
PART A – CANCELED WAREHOUSE RECEIPT(S)
5 Receipt No.	Enter the number of the canceled paper warehouse receipt(s) from the copy of the paper warehouse receipt.
6 Date Issued	Enter the date (MM-DD-YYYY) the canceled paper warehouse receipt(s) was (were) issued from the copy of the paper warehouse receipt.
7 Depositor or Owner	Enter the name of the depositor or owner exactly as written on the canceled paper warehouse receipt.
8 Product	Enter the kind of product on the canceled paper warehouse receipt from the copy of the paper warehouse receipt.
9 Grade	Enter the grade of the product on the canceled paper warehouse receipt from the copy of the paper warehouse receipt.
10 Weight Gross or Net	Enter the weight of the product on the canceled paper warehouse receipt from the copy of the paper warehouse receipt.
PART B – UNCANCELED WAREHOUSE RECEIPT(S)
In the certification.	Enter any new paper warehouse receipt numbers issued to replace not canceled warehouse receipts.
11 Receipt No.	Enter the number of the not canceled paper warehouse receipt(s) from the copy of the paper warehouse receipt.
12 Date Issued	Enter the date (MM-DD-YYYY) the not canceled paper warehouse receipt(s) was (were) issued from the copy of the paper warehouse receipt.
13 Depositor or Owner	Enter the name of the depositor or owner exactly as written on the not canceled paper warehouse receipt.
14 Product	Enter the kind of product on the not canceled paper warehouse receipt from the copy of the paper warehouse receipt.
15 Grade	Enter the grade of the product on the not canceled paper warehouse receipt from the copy of the paper warehouse receipt.
16 Weight Gross or Net	Enter the weight of the product on the not canceled paper warehouse receipt from the copy of the paper warehouse receipt.
PART C – CERTIFICATION
17A Warehouse Operator	Enter the name of the Warehouse Operator (Legal Entity) of the authorized person who is signing this oath.
17B Title	Enter the title of the Warehouse Operator (Legal Entity).
17C Warehouse Operator’s Signature	Enter the signature of the authorized person who is making the declaration. If you are mailing or faxing this form, print the form and manually enter your signature. If this form is approved for electronic transmission and you have established credentials with KCCO to submit forms electronically, use the buttons provided on the form for transmitting the form to the USDA servicing office.
17D Date	Enter the date (MM-DD-YYYY) of the signature in Item 17A.
18A Depositor’s or Owner’s Name and Address	Enter the Depositor’s or Owner’s Name and Address (including Zip Code).
18B Signature of Depositor or Owner	Enter the signature of the authorized person.
18C Date	Enter the date (MM-DD-YYYY) of the signature in Item 18A.

PART D – WITNESSES TO SIGNATURE

19A Name of Witness	Enter the name of the witnesses to this document.
19B Signature	Enter the signature of witnesses to this document.
19C Address	Enter the address (including Zip Code) of the witnesses to this document.

Page 4 of 4