WA-62 Bond to Cover Lost Paper Warehouse Receipts under the U.

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
WA-62
Farm Service Agency
(11-25-03)
United States Warehouse Act

Form Approved - OMB No. 0560-0120

1A. BOND NUMBER

BOND TO COVER LOST PAPER WAREHOUSE
RECEIPTS UNDER THE UNITED STATES WAREHOUSE ACT

1B. LICENSE NUMBER

(See Page 2 for Privacy Act and Public Burden Statements.)

2. We,

(a)

of

Name of the owner of the paper warehouse receipt(s)

(b)

City, State Address

as principal, and

(SELECT ONE OPTION - EITHER 3 or 4)
Residents of the State in which the paper warehouse receipt was issued, each of whom own real property valued, less
encumbrances and exceptions, at least at the penal sum of the bond.
3. We,

of (b)

(a)

City and State of Residence

Name of Individual

of (d)

(c)

City and State of Residence

Name of Individual

4.
Name of Corporate Surety (Include City and State address)

5. as surety, are held and firmly bound unto (a)
Warehouse Operator

(b)
Warehouse Operator's City, State Address

here after referred to as the Warehouse Operator,
6. In the penal sum of

(a)

$

dollars

(b)

($

)

(Double the value of the agricultural product at the time the bond is given)

to be paid to the warehouse operator, its heirs, executors, administrators, successors, or assigns, for which payment well and truly to be
made, we do bind ourselves, our heirs, executors, administrators, successors, or assigns, jointly and severally, firmly by these presents.
7. The conditions of this obligation are such that:
A. Paper warehouse receipts as follows were issued by

(1)
Name of Warehouse Operator

the warehouse operator, for agricultural products stored in the
(2)

Name of Warehouse

(3)
City and State Location
(4) Paper WHR No.

(5) Issued To

(6) Date Issued

(7) Grade

(8) Ag Product

(9) Weight

For in excess of five additional lost paper warehouse receipts, please attach an 8 ½ x 11 inch sheet of paper listing the receipts followed by the statement
."
"This listing is an integral part of bond number (10)
executed effective (11)

B. The principal has made and filed with the warehouse operator an affidavit showing that the principal is lawfully entitled to the possession of the
warehouse receipts listed and that the principal has not negotiated or assigned these warehouse receipts, that the warehouse receipts were lost or
destroyed, and that a diligent effort has been made to find the warehouse receipts without success; and

WA-62 (11-25-03) Page 2
C. The principal promises to deliver these warehouse receipts, if subsequently recovered, to the warehouse operator for cancellation; and
D. The principal has requested (Check one box):
(1) Delivery of the agricultural product evidenced by the paper warehouse receipt (s).
(2) Issuance of a duplicate paper warehouse receipt in lieu of the lost or destroyed paper warehouse receipt (bearing the same date of the
original warehouse receipt and subject to the same terms and conditions, and referencing the lost warehouse receipt number.
E. Therefore, if the principal indemnifies the warehouse operator against the original warehouse receipt, including all damages, costs, charges and
expenses that may arise from the delivery of the agricultural product or the issuance of a duplicate paper warehouse receipt and delivers for
cancellation the original warehouse receipt if subsequently located, then this obligation is void; otherwise, it remains in full force and effect.
F. The above bound parties have executed this agreement this:
(1)

Day of
Day

(2)

(3)
Month

Year

(8) Principal (If you executed Item 2, you must complete this section):
(a)
Principal - The owner of the paper warehouse receipts.
(b)
Signature

Witnesses: (c)

(e)

(d)
Name

City, State

(f)
City, State

Name

(9) Individuals Acting As Surety (If you executed Item 3, you must complete this section)
(b)

(a)

City, State

Name
(c)

(d)
City, State

Name

Witnesses:(e)

(f)
City, State

Name
(h)

(g)

City, State

Name

(10) Corporate Surety (If you executed Item 4, you must complete this section)
(a)
Surety
(b)
By
(c)
Title

Witnesses: (d)

(f)

(e)
City, State

Name
(g)
Name

City, State

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following
information is the regulations at 7 CFR Part 735. Furnishing the requested information is voluntary, however, without it, eligibility to remain licensed under the United States Warehouse Act must be
made in part on the basis of the information provided. 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 U.S.C. 286, 287, 371, 641, 651, 1001; 1014, and 31 U.S.C. 3729, may be
applicable to the information provided.
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 an OMB control
number. The valid OMB control number of this information collection is 0560-0120. The time required to complete this information collection is estimated to average 30 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. RETURN THIS

COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE (KCCO), WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205,
KANSAS CITY, MO 64141-6205.
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 martial 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, 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.