WA-70 Recept Signature Authority

Form Approved - OMB No. 0560-0120

WA-70

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(08-01-03)

RECEIPT SIGNATURE AUTHORITY
NOTE: The following statements are made in accordance with Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as
amended. 7 CFR Part 735 authorizes collection of the following data. Furnishing of the requested data is voluntary, and no penalty will be
imposed for failure to respond. However, a response is required in order to be considered for a warehouse license (7 U.S.C. 242) and the
decision as to the applicant's eligibility for a license must be made in part on the basis of the information provided. This information will not be
disclosed outside of the U.S. Department of Agriculture except as required by law to the Department of Justice and to the Department of the
Treasury. 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, 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 a valid OMB control number. The valid OMB control number for this information collection is 0560-0120.
The time required to complete this information collection 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. RETURN THIS COMPLETED FORM TO YOUR KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND
EXAMINATION DIVISION.
1. LICENSE NUMBER

2. DATE (MM-DD-YYYY)

NOTE: If Warehouse operator is a corporation, this form must be signed in accordance with the corporate
resolution on file.
This is to certify that the person whose signature, facsimile or electronic signature which appears in Item 4 has
been duly authorized to sign warehouse receipts issued under the U.S. Warehouse Act. Type of signature
authorized
Original
Facsimile
E-signature
3. NAME AND ADDRESS OF LICENSED WAREHOUSE (City, State and Zip Code)

4A. SIGNATURE OF PERSON AUTHORIZED TO SIGN RECEIPTS

4B. TYPE OR PRINT SIGNATURE OF PERSON AUTHORIZED TO
SIGN RECEIPTS

5. NAME OF LICENSED WAREHOUSE OPERATOR

6. BY

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 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964
(voice or TDD). USDA is an equal opportunity provider and employer.