WA-88 Receipt for Eligible Securities Accepted as Security

WA-88

Form Approved - OMB No. 0560-0120

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

RECEIPT FOR ELIGIBLE SECURITIES ACCEPTED AS SECURITY

2. City

1. WAREHOUSE OPERATOR

3. State

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

in the name of

A.

B.

TITLE OF SECURITIES

COUPON OR REGISTERED

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

4. Enter Applicable Name

C.
TOTAL FACE AMOUNT

D.

E.

F.

DENOMINATION

SERIAL NUMBER

INTEREST DATES

This receipt is executed in duplicate, and the original must be surrendered by the warehouse operator/securities owner before the
above described bonds or notes deposited are returned to warehouse operator/securities owner.

6. Date (MM-DD-YYYY)

7. Signature of Authorized Farm Service Agency Representative

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.