WA-372 Schedule of Charges

Form Approved - OMB No. 0560-0120

WA-372

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(08-01-03)

SCHEDULE OF CHARGES
TARIFF FOR STORING AND HANDLING AGRICULTURAL PRODUCTS
U.S. Licensed and Bonded Warehouse Operator
See Page 2 for Privacy Act and Public Burden Statements.
1. LICENSE NO.

2. WAREHOUSE NAME

3. LOCATION OF WAREHOUSE (Town and State)

All agricultural products received are considered to be deposited for storage under the terms of the U.S. Warehouse Act,
unless the owner of the agricultural products, or the owner's agent requests otherwise at or prior to the time of its acceptance
for delivery.
4. SERVICE

5. INSURANCE

6. This tariff is effective

, and supersedes all previous tariffs.
(Month, Day, and Year)

7. U.S. LICENSED AND BONDED WAREHOUSE OPERATOR

8A. By (Signature of Authorized Person):
8B. Type Name of Authorized Person:
8C. Type Title of Authorized Person:

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-372 (Page 2) (08-01-03)

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 United States Warehouse Act (7 U.S.C. 242). The information will be used in part to
determine a warehouse operator's eligibility for a USWA license. Furnishing the requested information is voluntary. Failure to furnish the requested
information may result in denial of a license or suspension of your USWA license. 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 USC 286, 287, 371, 641, 651, 1001; and 31 USC 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, WAREHOUSE LICENSE AND EXAMINATION DIVISION.