WA-237 Order for Printing U.S. Warehouse Receipt Forms

WA-237

Form Approved - OMB No. 0560-0120
1. MAIL OR FAX TO:
FAX No. (816) 926-1548

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(08-18-04)

CHIEF
LICENSING BRANCH
P.O. BOX 419205
STOP 9148
KANSAS CITY, MISSOURI 64141-6205

ORDER FOR PRINTING U.S. WAREHOUSE RECEIPT FORMS
(See Page 2 for Privacy Act and Public Burden Statements)

2. FOR FSA USE ONLY
B. CONTACT INFORMATION

A. VENDOR NAME

4. LICENSE NO.

5. PRINT:
RECEIPT NUMBER

3. ORDER NO.

CCC WAREHOUSE CODE NO.
CONTROL NO.

6. NAME OF WAREHOUSE

7. LOCATION OF WAREHOUSE

8. NAME OF WAREHOUSE OPERATOR
9. INCORPORATED UNDER THE LAWS OF STATE OF: (If not incorporated, show "None.")
11.
SERIALLY NUMBERED

10.
QUANTITY WANTED

TO

FROM

12.
COPIES IN SET
(Excluding original)

13.
TYPE ASSEMBLY
DESIRED

NOTE: Duplicate copy of UGRSA grain receipts will be fully printed on salmon paper. Record Copy (to remain in book) - White
14. COMMODITY TO BE COVERED: (Check one)
COTTON
RICE

GRAIN

OTHER (Specify)

15. KIND OF RECEIPT: (Check one)
BEARER

NONNEGOTIABLE

ORDER

16. INSURANCE STATEMENT: (Check one)
ALL RISK
FULLY INSURED
(Except war risk)
(Standard policy)

NOT INSURED

17A TYPE OF RECEIPT: (Check one)
SINGLE BALE

MULTIPLE BALE

UGRSA (Grain)

SPECIAL FORM (Copy attached)

STANDARD (Type)

18. OVERPRINT: (Check appropriate box(es) below) (Red ink will be used unless otherwise specified.)
LICENSED WEIGHER

NOT GRADED ON REQUEST OF DEPOSITOR

OTHER (Specify exact wording)

19. WAREHOUSE RATES IN LIEN COLUMN? (Check one)
If "YES," specify exact wording
YES
NO

20. SHIP TO: (Specify exact name and address, including ZIP Code
to which receipts are to be shipped.)

21. REMARKS

SHIP BY: (Method)
22. FOR USDA USE ONLY

23. When this order is filled please have contract printer send statement of
charges. A check will be promptly forwarded.
A. NAME

A. APPROVED BY
(FOR U.S. DEPARTMENT OF AGRICULTURE)

(LICENSED WAREHOUSE OPERATOR)
B. SIGNED

B. DATE APPROVED

C. DATE SIGNED

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 1 of 2

WA-237 (Page 2 of 2) (08-18-04)
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.
The authority for requesting the following information is 7 CFR Part 735. The information will be used to order warehouse receipts for warehouse
operators. Furnishing the requested information is voluntary and no penalty will be imposed for failure to respond. However, a response is required in
order to be considered for a warehouse license (7 U.S.C. 242). 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 10 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 P.O. BOX 419205, STOP 9148, KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND
EXAMINATION DIVISION.