WA-125 Memorandum of Adjustments

Form Approved - OMB No. 0560-0120

WA-125
(02-10-04)

UNITED STATES DEPARTMENT OF AGRICULTURE
Farm Service Agency

MEMORANDUM OF ADJUSTMENTS
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 report is authorized by law, 7 U.S.C. 242 and
15 U.S.C. 714 (Commodity Credit Corporation Charter Act). Furnishing the requested information is voluntary, however a penalty may be imposed for failure to respond. The data collected serves as
record of deficiencies found during a warehouse examination. Failure to respond regarding correction of the deficiencies and corrective actions taken may result in suspension of license or contract
removal. This data may be furnished to any agency responsible for enforcing regulations of the U. S. Warehouse Act. 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 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 KANSAS CITY COMMODITY OFFICE, P.O. BOX 419205, Stop 9148, KANSAS CITY, MO. 64141-6205.

1. NAME OF WAREHOUSE

2. LICENSE AND OR CODE NO.

5. TYPE OF EXAM
Original

3A. LOCATION

3B. COUNTY

4. DATE OF EXAMINATION

Amendment
Subsequent
Special

6. EXAMINER EXCEPTION (continued on page 2)
An examination of this warehouse and the agricultural products stored therein disclosed the following conditions which must be corrected as soon as possible. The corrective
action must be reported on the reverse of this form and mailed to the office shown in item 12 within 15 days of the date you received this form. If all corrections are not completed
within 15 days, you should report your progress at 15-day intervals until all corrections are completed. These conditions may also be in violation of various Federal or state criminal
or civil statutes, program regulations, or your contract with the Commodity Credit Corporation. The issuance of this form is a report of the conditions found at this examination and
is not an election by the United States or Commodity Credit Corporation of actions to be taken. Issuance of this form and compliance with the requirements herein by the
warehouse operator do not and will not affect or limit the administrative, criminal, or civil action which the United States or Commodity Credit Corporation may take under criminal or
civil statutes, the contract, or the program regulations:

7A. WAREHOUSE EXAMINER (Signature)

7B. DATE PREPARED (MM-DD-YYYY)

I acknowledge receipt of this form.
8. WAREHOUSE OPERATOR

9. BY (Signature)

10. DATE (MM-DD-YYYY)

11. TITLE

12. REPORT TO BE SUBMITTED TO:

CHIEF, WAREHOUSE LICENSE AND EXAMINATION DIVISION
KANSAS CITY COMMODITY OFFICE, FSA
P.O. BOX 419205 - STOP 9148
KANSAS CITY, MISSOURI 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.

WA-125 (02-10-04) (Page 2)
EXAMINER EXCEPTION (continuation)

WA-125 (02-10-04) (Page 3)
13. WAREHOUSE OPERATOR'S REPORT OF ACTION TAKEN

14. This section must be completed when grain is purchased by the warehouse operator to regain a sufficient inventory balance to meet all storage
obligations.
A.
DATE

B.
KIND

C.
BUSHEL
AMOUNT

D.
TYPE
PURCHASE 1/

E.
CHECK
NO. 2/

1/ New grain, warehouse receipts, open storage, other.

F.
DATE
ISSUED

G.
DOLLAR
AMOUNT

H.
PURCHASED
FROM

2/ If not paid, indicate "Contract Number"

15. CERTIFICATION OF WAREHOUSE OPERATOR

The information contained in the "Warehouse Operator's Report of Action Taken" is, to the best of my knowledge and information,
true and correct, and a complete statement of the actions taken. I understand that a false statement or representation herein or in
any subsequent report, may subject me to criminal and civil action taken under the statues of the United States including 15 U.S.C.
714m and 18 U.S.C. 1001.
A. SIGNATURE

B. TITLE

C. DATE (MM-DD-YYYY)