FGIS 961 Official Grain Weight Certificate (Divided)

OMB No. 0580-0013 Statement on Reverse

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UNITED STATES DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

U.S. GRAIN STANDARDS ACT

OFFICIAL GRAIN WEIGHT CERTIFICATE
(ISSUED AT)

DIVIDED LOT - ORIGINAL
NOT NEGOTIABLE

US(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 weigh the kind of grain covered by this
certificate and that on the above date the following identified grain was weig hed under the Act, with the following results:
Kind of Grain

Identification of Carrier

Location of Grain

Net Weight Divided (pounds)
This grain was officially weighed as an undivided lot of ______________________ ____________________ pounds.
No part of the lost was officially weighted as a separate unit.
Remarks and Stowage

Name and Signature

This certificate is issued under the authority of the United States Standards A ct, 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, conditions, 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 consider ed representative of the lot if the grain is
transshipped or is otherwise transferred from the identified carrier or contain er 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 Stat es as prima facie evidence of the truth of the facts stated therein. This cert ificate does not excuse failure to comply with the
provisions of the Federal Food, Drug, and Cosmetic Act, or other Federal law.

WARNING: Any person who shall knowingly falsely make, issue, alter, forge, or counterfei t this certificate, or participate in any such actions, or otherwise violate pr ovisions in the U.S. Grain
Standards Act, the U.S. Warehouse Act, or related Federal laws is subject to cr iminal, civil, and administrative penalties.
The conduct of all services and the licensing of personnel under the regulation s governing such services shall be accomplished without discrimination as to race, color, religion, sex, national origin, age,
or handicap.

FORM FGIS-961 (4-99) All previous editions are obsolete

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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 complete this information collection is estimated to average 34 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintain ing the data needed, and completing the reviewing the collection of information.
FORM FGIS 961 REVERSE