Form FNS-57 Report of Shipment Recieved, Over, Short and/or Damaged

FORM APPROVED OMB NO. 0584-0293
U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE

REPORT OF SHIPMENT RECEIVED OVER, SHORT AND/OR DAMAGED
SEE INSTRUCTIONS ON REVERSE
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 0584-0293. The time
required to complete this information collection is estimated to average 5 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection.

SECTION A - SHIPMENT IDENTIFICATION AND UNLOADING INFORMATION
4. DESTINATION CITY AND STATE

1. NAME OF COMMODITY

2. TYPE OF PACK

3. CONTRACT NO.

5. DELIVERY ORDER NO.

6. NOTICE TO DELIVER NO.

7. METHOD OF DELIVERY
RAIL

TRUCK

8. RR CAR, TRUCK, OR PIG NO.
PIGGYBACK
10. OCEN BILL OF LADING NO.
(Overseas Shipment Only)

9. UNLOADED
STARTED (Date and Time)

COMPLETED (Date and Time)

SECTION B - OVERAGE, SHORTAGE, AND/OR DAMAGE
11. QUANTITY
B. AMOUNT RECEIVED IN GOOD
CONDITION

A. REPORTED SHIPPED

12A. DAMAGE/OVERAGE/SHORTAGE

C. OVER

E. DAMAGED

D. SHORT

F. HIDDEN DAMAGE

13. CARRIER'S AGENT PRESENT DURING
UNLOADING

12B. HOW DISCOVERED

WHEN DISCOVERED
BEFORE
UNLOADING

DURING
UNLOADING

AFTER
UNLOADING

UNLOADING
TALLY

PHYSICAL
RECOUNT

OTHER

YES

NO

14. DOOR SEAL NUMBERS
B. OUTBOUND SEAL NUMBERS (If Applicable)

A. INBOUND NUMBERS AND CONDITION OF SEALS

15. CARRIER'S AGENT NOTIFICATION
A. NAME OF AGENT
C. HOW NOTIFIED

B. DATE NOTIFIED

16. DID CARRIER'S AGENT RESPOND TO NOTIFICATION?

IN PERSON

FAX

TELEPHONE

E-MAIL

YES (In what way)

NO (Explain)

17. COMPLETE IF APPLICABLE
A. WAS MECHANICAL REFRIGERATION, EQUIPMENT OPERATING
YES

B. TEMPERATURE OF REFRIGERATION UNIT/INTERIOR TEMP/COMMODITY

NO

CONSIGNEE CERTIFICATION
I CERTIFY the information and statements above are, to the best of my knowledge and belief, true and correct.
DATE

SIGNATURE OF CONSIGNEE OR REPRESENTATIVE

CARRIER CERTIFICATION
Receipt of a copy of this report is hereby acknowledged and the facts contained herein are verified.
SIGNATURE OF CARRIER'S AGENT

NAME AND ADDRESS OF CARRIER

DATE

CARRIER REMARKS

REMARKS (IF DAMAGED, PLEASE INDICATE NATURE AND DISPOSITION OF THE DAMAGE)

FORM FNS-57 (5-98) Previous editions obsolete
Electronic Form Version Designed in JetForm 5.01 Version

ORIGINAL - Send to Kansas City Commodity Office,
(Include all supporting Documentation)

INSTRUCTIONS
This report is to be prepared whenever a shipment is
received over, short, and/or damaged.

11E. Record the number of units received damaged of the
quantity reported shipped on the 269A.

SECTION A - SHIPMENT IDENTIFICATION/
UNLOADING INFORMATION

11F. Record the number of units received damaged of the
quantity reported shipped on the 269A after unloading.

This section will be completed at all times to identify
the shipment being reported as over, short and/or
damaged.

12A. Check applicable box.

ITEM
1.

Self-explanatory.

2.

Show type of pack, such as case 6/10's, case
12/No. 3 cylinders, 50# bag, etc.

3.

Self-explanatory.

4.

Self-explanatory.

5.

Record Delivery Order No including Commodity
Code.

6.

Record the Notice to Deliver No. shown in the
space marked "N/D No." in the upper right on
the KCCO 269A.

7.

Check applicable box.

8.

Record railroad car number, truck, or piggyback
number.

9.

Record date and time unloading started, and date
and time unloading was completed.

10. When applicable, record the ocean bill of lading
number, (For Overseas Shipments ONLY)
SECTION B - OVERAGE, SHORTAGE, AND/OR
DAMAGE
When a shipment is received over, short, and/or
damaged, items 11 through 16 should be completed.
11A. Record the number of units shown on the (KCCO)
269A, Forwarding Notice.
11B. Record the number of units received.
11C. Record the number of units received over the
quantity reported shipped on the 279A.
11D. Record the number of units received short of
the quantity reported shipped on the 269A.

12B. Show the information that will establish proof that the
shipment was actually over, short, and/or damaged.
13. Check applicable box to show whether or not
carrier's agent was present from time car or truck
was opened until unloading was completed.
14A. Record the inbound seal numbers on all doors and the
condition of the seals. If shipment was made and
not sealed, show "no seals."
14B. If applicable, intermediate consignees on split shipments shall record the seal numbers placed on all
doors.
15A,B, C. Complete all three items.
16. If the "yes" box is checked, explain how the agent
responded (for example: made personal inspection;
advised that they would not be available; advised
consignee's inspection would suffice, etc.)
If the carrier's agent did not respond, explain why
(for example: no agent available; refused to inspect;
did not acknowledge, etc.)
17A.Check applicable boxes.
17B. Record the temperature of the refrigeration unit
located on the outside of the trailer, interior temp/
commodity.
CONSIGNEE'S CERTIFICATION
Self-explanatory.
CARRIER'S CERTIFICATION
Request that the carrier's agent complete these items, if
the agent refuses, and if available, request a copy of the
carriers )S&D report. If the carrier does not have a report
make the following notation "Agent (insert name of driver)
of (insert name of carrier) did not agree with this report.
The reason for the dispute is (give brief explanation). A
copy of the report was given to him/her on (insert date)."
If the carrier's signature cannot be obtained within 10
days or if the carrier is not available, make the following
notation "carrier did not respond" or carrier is not available."

NOTE: Only one form needs to be completed for a consolidation shipment. Make sure all overages, shortages and
damages are fully explained. If necessary please attach a separate sheet. Item 6 - please list the consolidation
number rather than the ND.

COPY 1 - To agent of the delivering carrier.

COPY 2 - For use of the distributing agency.