WA-125ER Memorandum of Adjustments - Electronic Response

This form is available electronically.
U.S. DEPARTMENT OF AGRICULTURE
WA-125ER
Farm Service Agency
(12-03-03)
United States Warehouse Act

Form Approved - OMB No. 0560-0120
A. License No.

B. Code No.

MEMORANDUM OF ADJUSTMENTS ELECTRONIC RESPONSE

C. Date of Exam

(See Page 2 for the Privacy Act and Public Burden Statements)

Continuation from WA-125, Memorandum of Adjustments:
13. Warehouse Operator's Report of Action Taken

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 martial 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, Office of Civil Rights, Room 326-W, Whitten Building, 1400 and 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-125ER (12-03-03) Page 2

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
(MM-DD-YYYY)

B.
Kind

C.
Bushel
Amount

D.
Type
Purchase 1/

E.
Check
Number 2/

F.
Date Issued
(MM-DD-YYYY)

G.
Dollar
Amount

H.
Purchased From

1/ New grain, warehouse receipts, open storage, other.
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 statutes of the United States including 15 U.S.C., 714 m, and 18 U.S.C. 1001.
15A. Signature

NOTE:

15B. Title

15C. Date (MM-DD-YYYY)

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. 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 licensing agreement
between the warehouse operator and the Deputy Administrator for Commodity Operations. Furnishing the requested information is voluntary, however, without it,
eligibility to remain licensed under the United States Warehouse Act must be made in part on the basis of the information provided. 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; 1014, 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.