FGIS 909-1 Official Export Grain Inspection Certificate (Divided -L

FGIS FORM 909-1
MAY 04
(Edition FEB 00 may be used)

APPROVED OMB NO. 0580-0013
(See reverse for statement)

UNITED STATES DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

DIVIDED LOT - ORIGINAL
NOT NEGOTIABLE
U.S. GRAIN STANDARDS ACT
OFFICIAL EXPORT GRAIN INSPECTION CERTIFICATE

USISSUED AT

DATE OF SERVICE

I certify that I am licensed or authorized under the United States Grain Standards Act (7 U.S.C. 71 et seq.) to inspect the kind of grain covered by this
certificate and that on the above date the following identified grain was inspected under the Act, with the following results:

Original
Inspection

Appeal
Inspection

Reinspection

Board Appeal
Inspection

QUANTITY (This is NOT a weight certificate)

LOCATION

IDENTIFICATION OF CARRIER

GRADE AND KIND (In accordance with the Official Grain Standards of the United States)

STOWAGE

REMARKS

APPEAL NO

(If applicable)

APPLICANT

NAME AND SIGNATURE

This certificate is issued under the authority of the United States Grain Standards Act, as amended (7 U.S.C. 71 et seq ) , and the regulations thereunder (7 CFR 800.0 et seq .). It is
issued to show the kind, class, grade, quality, condition, or quantity of grain, or the condition of a carrier or container for the storage or transportation of grain, or other facts relating to
grain as determined by official personnel. The statements on the certificate are considered true at the time and place the inspection or weighing service was performed. The certificate
is not considered representative of the lot if the grain is transshipped or is otherwise transferred from the identified carrier or container or if grain or other material is added to or
removed from the total lot. If this certificate is not canceled by a superseding certificate, it is receivable by all officers and all courts of the United States as prima facie evidence of the
truth of the facts stated therein. This certificate does not excuse failure to comply with the provisions of the Federal Food, Drug, and Cosmetic Act, of other Federal law.
WARNING: Any person who shall knowingly falsely make, issue, alter, forge, or counterfeit this certificate, or participate in any such actions, or otherwise violate provisions in the
U.S. Grain Standards Act, the U.S. Warehouse Act, or related Federal laws is subject to criminal, civil, and administrative penalties.
The conduct of all services and the licensing of personnel under the regulations governing such services shall be accomplished without discrimination as to race, color, religion, sex, national origin,
age, or handicap.

EXPORT

FORM FGIS-909-1 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 is 0580-0013. The time required to disclose this recordkeeping requirement is to
average 0.5 hours per recordkeeper annually, including the time to retain such records, and to notify, disclose, and report to third parties such
recordkeeping requirements.