WA-139 Certificate of Loss of Canceled Or Uncanceled Warehouse

This form is available electronically.

Form Approved – OMB No. 0581-0305 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-139 (07-31-18)

U.S. DEPARTMENT OF AGRICULTURE Agricultural Marketing Service

1. Type of Warehouse Receipt(s) (Check One Below):

2. License Number

Canceled

Uncanceled

     

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

Negotiable

Nonnegotiable

3. Name of Warehouse

     

4. Warehouse Location (City and State as shown on License)

     

PART A – CANCELED WAREHOUSE RECEIPT(S)

IT IS HEREBY CERTIFIED THAT the warehouse receipt(s) identified below, issued by the undersigned warehouse operator operating under provisions of the United States Warehouse Act and the regulations thereunder, was lost or misplaced by said warehouse operator after issuance to and return by the undersigned depositor or owner of said receipt(s) and that after diligent search such receipt(s) cannot be found by said Warehouse Operator. The person signing below as depositor or owner witnesses these facts and acknowledges delivery of said product(s) by said warehouse operator. He or she further stipulates that on the date indicated herein he or she was the lawful owner of said warehouse receipt(s). Said warehouse operator agrees to save harmless any innocent third party in event of the reappearance of said lost warehouse receipt(s).

5. Receipt No.

6. Date Issued (MM-DD-YYYY)

7. Depositor or Owner

8. Product

9. Grade

10. Weight Gross or Net

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART B – UNCANCELED WAREHOUSE RECEIPT(S)

IT IS HEREBY CERTIFIED THAT the warehouse receipt(s) identified below, prepared by the undersigned Warehouse Operator operating under provisions of the United States Warehouse Act and the regulations thereunder, was lost or misplaced by said warehouse operator after prepared and prior to the delivery of the receipt(s) or the product(s) covered thereby to the undersigned depositor; and that after diligent search such receipt(s) cannot be found by said Warehouse Operator. The person signing below as depositor

or owner witnesses these facts and acknowledges receipt of a new warehouse receipt(s) Nos.

     

     

or delivery of said product(s) in lieu thereof. Said Warehouse Operator agrees to save harmless any innocent third party in event of

the reappearance of said lost warehouse receipt(s).

11. Receipt No.

12. Date Issued (MM-DD-YYYY)

13. Depositor or Owner

14. Product

15. Grade

16. Weight Gross or Net

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART C - CERTIFICATION

Under penalty of perjury, I declare that I have examined the foregoing certificate and that to the best of my knowledge and belief, it is a true, correct, and complete statement.

17A. Name of Warehouse Operator (Legal Entity)

17B. Title

     

     

17C. Signature of Warehouse Operator

17D. Date (MM-DD-YYYY)

     

18A. Depositor’s or Owner’s Name and Address (Including Zip Code)

18B. Signature of Depositor or Owner

18C. Date (MM-DD-YYYY)

     

     

PART D – WITNESSES TO SIGNATURE

19A Name of Witness

19B Signature

19C Address

     

     

     

     

     

     

WA-139 (07-31-18) 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 identify paper warehouse receipts lost by warehouse operators either canceled or not canceled. 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 a valid OMB control number. The valid OMB control number for this information collection is 0581-0305. 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 WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

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 Warehouse and Commodity Management Division (WCMD), STOP 9148, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 844-930-0174

Customers who have established electronic access credentials with WCMD may electronically transmit this form to WCMD. Features for transmitting the form electronically are available to those customers who would like to establish online access credentials with WCMD, follow the instructions provided at the USDA eforms web site.

Warehouse Operators prepare the form, return the original to WCMD 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.