Form KC-5 Rate Quotation for Transportation Services

Form Approved - 0560-XXXX
KC-5 U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency RATE QUOTATION FOR TRANSPORTATION SERVICES				1. SOLICITATION NUMBER	2. COMMODITY
				     	     
3.	4.	5.		6.	7.		8.
ITEM NUMBER	RATE PER LOAD	ORIGIN CITY, STATE		DESTINATION CITY, STATE	TOTAL GROSS WEIGHT		TOTAL TRUCKS OFFERED FOR THIS ITEM
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
     	     	     		     	     		     
9. COMMENTS
     
This quote is in response to the solicitation number indicated above and is inclusive of all charges including any fuel surcharge. All terms and conditions of the referenced solicitation, and the following as appropriate shall apply: Revised Standard Rules Tender or Standard Operating Agreement, and Brokerage Agreement.
10. SIGNATURE (Must be an authorized official)			11. PRINT NAME
			     
			12. COMPANY NAME
			     
13. FAX TRANSMITTAL a. No. of pages transmitted      
b. TO:			d. FROM:
KCCO-TCAB			     
c. FAX:			e. PHONE (Include area code):			f. FAX:
(816) 926-6072			      Ext.     			     

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is 49 USC 13102 (2), 13712 and 49 CFR Chapter 10. The information will be used to establish the motor carrier transportation needs of the U.S. Department of Agriculture, Farm Service Agency, Kansas City Commodity Office for the movement of its freight. Furnishing the requested information is to ensure that motor carriers providing transportation service have both the willingness and capability to meet these needs. Failure to furnish the requested information will result in a motor carrier to be considered non-responsive. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided.

Federal Agencies may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to U. S. Department of Agriculture, Kansas City Commodity Office (OMB No. 0560-XXXX), Chief, Planning and Analysis Division, Stop 8768, Kansas City, Missouri 64141-6205.

NONDISCRIMINATION STATEMENT

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 and Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.