WA-87 Receipt for Obligor on Return of Securities

WA-87

Form Approved - OMB No. 0560-0120

(10-09-03)
UNITED STATES DEPARTMENT OF AGRICULTURE
Farm Service Agency

RECEIPT FOR OBLIGOR ON RETURN OF SECURITIES

3. State

2. City

1. WAREHOUSE OPERATOR

The undersigned hereby acknowledges receipt of the securities herein-after described, deposited with THE SECRETARY
OF AGRICULTURE as security in lieu of surety or sureties on UNITED STATES WAREHOUSE ACT BOND filed with THE
DIRECTOR, KANSAS CITY COMMODITY OFFICE, for WAREHOUSE OPERATOR'S BOND. Said securities 1/ are registered
in the name of

.

, and are assigned
4. Enter Applicable Name

5. in blank; to bearer; or to [identity of assignee];
See 31 CFR Part 306.41

A.

B.

C.

D.

E.

TITLE OF SECURITIES

COUPON OR
REGISTERED

TOTAL FACE AMOUNT

DENOMINATION

SERIAL NUMBER

F.
INTEREST DATES

This receipt is executed in duplicate.

6. Date (MM-DD-YYYY)

7. Signature of Warehouse Operator/Securities Owner

1/ This information to be furnished only in case of registered securities.

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. 7 CFR Part
735 authorizes collection of the following data. Furnishing the requested information is voluntary. However, if information is not furnished, activities related to
bonding may not be conducted or approved and may form the basis for continued eligibility for licensing. 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, 15 U.S.C. 714m, 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 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 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.