WA-225 Warehouse Operator's Statement and Examiner's Comparison

Form Approved - OMB No. 0560-0120
U.S. DEPARTMENT OF AGRICULTURE 1. NAME AND LOCATION OF WAREHOUSE (City and State) 2. LICENSE AND CODE
No.
Farm Service Agency

WA-225
(06-02-05)

WAREHOUSE OPERATOR'S STATEMENT AND EXAMINER'S
COMPARISON OF OBLIGATED STOCKS
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. 7 CFR Part 735 authorizes the collection of the following data. This data is being collected
to comply with the U.S. Warehouse Act, 7 U.S.C. 242 and Standards for Approval of Cotton Warehouses, 7 CFR Part 1427. Data is used to determine whether licensee has required facilities and is operating in accordance with the Act,
regulations or contractual requirements. No warehouse license or contract approval may be granted unless pertinent information is obtained. Furnishing the data is voluntary; however, without it assistance cannot be provided. This information
may be furnished to any agency responsible for enforcing the provisions of the Act. 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 the Department
of 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 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the date needed, and maintaining the data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND
EXAMINATION DIVISION, P.O. Box 419205, Kansas City, MO 64141-6205.

4. UNISSUED RECEIPTS ON HAND

3. PAPER/CARD RECEIPTS ISSUED SINCE LAST EXAMINATION
A.
BEGINNING NO.

B.
ENDING NO.

D. TOTAL

C.
NO. ISSUED

A.
BEGINNING NO.

¢

C.
NO. ON HAND

B.
ENDING NO.

¢

D. TOTAL

5. BONDS COVERING LOST OR DESTROYED RECEIPTS (List on WA-101)
6. ELECTRONIC STORAGE OBLIGATIONS AND STOCKS ON HAND:
RECEIPTS

A.
TYPE (ELECTRONIC)

B.
OUTSTANDING THIS POSTED
DATE

(1) MULTIPLE FORM RECEIPTS
(2) UNITS
(3) SINGLE FORM RECEIPTS AND UNITS
(4) TOTAL UNITS:

¢

7. PAPER STORAGE OBLIGATIONS AND STOCKS ON HAND:
A.
TYPE (PAPER)

B.
OUTSTANDING AT LAST
POSTED DATE

RECEIPTS
D.
C.
CANCELED SINCE LAST
ISSUED SINCE
POSTED DATE
LAST CUT-OFF

E.
OUTSTANDING THIS POSTED
DATE

(1) MULTIPLE FORM RECEIPTS
(2) UNITS
(3) SINGLE FORM RECEIPTS AND
UNITS
(4) TOTAL UNITS
F. Non-Receipted Obligations:

¢

G. NET TOTAL UNITS (ITEM 6(4) B , ITEM 7(4) E) and F : Represented by Receipted and Non-Receipted at time of cut-off:

¢

8. DOES THE WAREHOUSE RECORDS MATCH THE PROVIDER'S RECORDS?

YES

NO (IF "NO", NOTE ON WA-101 or WA-125)

9. DO YOU HAVE ANY TYPE OF AGREEMENT WITH A FIELD WAREHOUSE COMPANY?
YES
NO
IF "YES", HAS THIS BEEN CLEARED WITH USDA?
YES
NO (If "NO" furnish copy to examiner).
WAREHOUSE OPERATOR'S CERTIFICATION: I hereby certify to the U.S. Department of Agriculture and the Commodity Credit Corporation, subject to penalties of applicable laws for
knowing false representations and similar offenses (e.g., 15 U.S.C. 714m and 18 U.S.C. 1001) that the information contained in the above Warehouse Operator's Statement is, to the best of my
knowledge and belief, a true, correct and complete statement, and that I have no obligations as a warehouse operator to deliver any agricultural product to any person as of the date and hour shown
above, other than as indicated in this statement. I understand that the examination by a representative of the U.S. Department of Agriculture in connection with which this statement is furnished and
the information contained herein does not relieve me of any responsibilities under the U.S. Warehouse Act of any Agreement I have entered into with the Commodity Credit Corporation.
10A. SIGNATURE OF WAREHOUSE
OPERATOR OR AUTHORIZED AGENT

10B. TITLE

10C. DATE (MM-DD-YYYY)

10D. NAME OF WAREHOUSE EXAMINER
WITNESSING SIGNATURE

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.

Page 2

WA-225 (06-02-05)
11. EXAMINER'S COMPARISON OF WAREHOUSE OPERATOR'S OBLIGATIONS AND INVENTORIED STOCKS:
UNIT CHECK
A. TOTAL STOCKS ON HAND:

COUNT

B. CUT-OFF DATE:
STATISTICAL

C.
UNIT CHECK

D.
COUNT

E.
STATISTICAL

F.
ALL OTHER

12. STOCK VARIANCES (List on WA-101 or WA-125)
13. COMPARISON OF WAREHOUSE OPERATOR'S STORAGE OBLIGATIONS AND INSURANCE IN EFFECT. DO NOT COMPLETE COLUMNS
13E and 13F WHERE COTTON STOCKS ARE COVERED BY 100%, NO-LIMIT REPORTING FORM POLICY.
A.
STOCKS

INVENTORY UNITS
D.
TOTAL

C.
NOT INSURED

B.
INSURED

E.
VALUE OF INSURED
STOCK

F.
INSURANCE IN
EFFECT

(1) Covered by receipts
(2) Not covered by receipts
TOTALS

¢

14. STOCKS NOT COVERED BY INSURANCE REPORTED BELOW BELONGING TO:
A. CCC:
15A. IF REPORTING FORM INSURANCE IS
CARRIED, WHEN WAS LAST REPORT
SUBMITTED?

B. OTHERS:
15B. DID REPORT TO INSURANCE
COMPANY CORRESPOND WITH
WAREHOUSE RECORDS?
YES

15C. IF "NO", EXPLAIN:

NO

16. INSURANCE POLICIES IN EFFECT WHICH COVER STOCKS:
A.
POLICY NO.

17. NUMBER OF BALES

B.
INSURANCE COMPANY

18. VALUE PER BALE

$
20A. SIGNATURE OF EXAMINER

AMOUNT OF INSURANCE

C.
EXPIRATION
DATE (MM-DD-YYYY)

D. FIRE

E. EXTENDED COVERAGE

$

$

$

$

$

$

19. TOTAL VALUE

$
20B. DATE (MM-DD-YYYY)