WA-105 Returned and Destroyed Receipt Record

Form Approved - OMB No. 0560-0120

See Page 2 for Nondiscriminatory, Privacy Act and Public Burden Statements.
U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

WA-105
(11-01-03)

RETURNED AND DESTROYED RECEIPT RECORD
1. NAME AND ADDRESS OF WAREHOUSE OPERATOR

2. NAME AND LOCATION OF WAREHOUSE

3. LICENSE NO.

PART A - RECEIPTS
DESTROYED

RECEIVED

RETURNED TO WAREHOUSE OPERATOR

NUMBERED
4.
DATE
(MM-DD-YYYY)

5.
FROM

6.
TO

7.
BY WHOM

8.
DATE

9.
BY WHOM

10.
DATE

11.
BY WHOM

12.
RECEIVED BY

(MM-DD-YYYY)

(MM-DD-YYYY)

PART B - LICENSES
RETURNED TO KCCO

RECEIVED

RETURNED TO WAREHOUSE OPERATOR

NUMBERED
13.
DATE

14.
LICENSE
NO.
(MM-DD-YYYY)

15.
NAME

16.
BY WHOM

17.
DATE
(MM-DD-YYYY)

18.
BY WHOM

19.
DATE

20.
BY WHOM

21.
RECEIVED BY

(MM-DD-YYYY)

22. REMARKS

23. I authorize destruction of the above forms.
A. SIGNATURE OF AUTHORIZED OFFICER OR
MANAGER

B. DATE (MM-DD-YYYY) C. SIGNATURE OF WAREHOUSE
EXAMINER

D. DATE (MM-DD-YYYY)

WA-105 (11-01-03) (Page 2)

N
O
T
E

The following statements are 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. The information will be used to complete the terms of a license and contract between the
warehouse operator and Deputy Administrator Commodity Operations. Furnishing the requested information is voluntary, however, without it a record of unused
warehouse receipts surrendered by the warehouse operator for any reason would be difficult to complete. 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, 1001; 1024, 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, 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.