Form KC-269 Notice to Deliver (Self Certification)

_ ••••..••..
I\••.~••II•.I ••••
,,_

.
-269
NOTICE
I

x..,,;.a, City FSA Commodify Of5c.

OOC!:;i
PY
PC
UNITS
RECE!VED
OMM..
CUNliS
OMM.
CODE
SIZ;NET
eROS
UNITS
WEICHT
SRECE!V!:D
W!:ICHi
NEi
WEICiii
SIZE-TYPE
UNITS
C~RTiFIC':'
No.
OF
UNITS
HEi
W!:ICHT
OF
UN
CIS
COOE
PC
iE
Ot.i'E
No.
6Y
~EC'::J
(SICNA
iURE
ili'.OJ
TiTLEl I
UNliS
WEICHT
RECE!VEO
D":"E
REC'O
3Y
ISIC.,<':'
TUR" &&RECEIVED
GRO
5S
WEICHi
;;::
EX
~/C
,'//0
'10.
:'i••
PRCCR;'M
C:RiIFIC;'
No,
TYPE
DESTIN':"
MI~ES
UNITS
NET
UNI":
?,;...i:
PY
WEICHi
nON
10
CliY
' CROSS
&.
57;"
iEIE
SIZE
- TYP=
UNITS
..•
CONTRACT
INVITATiON
UNliS
i~t:.;'iS
Ne.
.'rice:
No. TYP!:
OR
WHSE.
CODE
.A.NNOUNCEMENi
CROSS
CESTINA
C~RilFl~
'NEICi-!i
nON
CilDSS
WEIGHi
DE~
YW!:ICHT
C;'R"
F03
OR
,=.:.S CITYNQ.& Si A iE
OAT;
S
bilJ.d ,"6.
W.'~llt
f.v.r:,
OlSPOSliION
NUMSER
DISPOSiTiON
,':
••EX
COOE
Fca CEiHIFIC.t.;
:.' WEICHT
F.:.S
.bUled
..
:C/O
~Q.
O~ja
M
R
S
::
Il'ld
rteaivtd
wti9i'lf
OEL ",
y ?hone
=.:.RFL
OIS?OSITION
0 IS? 0 SITION NUMSER
HUMS ER
SERVIC:NC
C:'RRIE.'
CRACE
MCUTINC
4'COMM.Ord.,
:q\llIU"."t.
COD:
?C
C :::MMCOI7Y
OESC.:U?'iICN
-

....

"

I

f."I'll;U

~U·_'.n

CONSICNE:

IC.~E;

~=C;tPT

RECEIPT

FOR

FOR

I

.,

I

PAGE _
CONSIGNE:
,CONSIGNE::

C~fi=.

PORTION

I

I

-

FORM

APPROVED

- OIolS N•• 056

0-01'77

-I

-.

.. .
..
py
CONSIGNEe
~":'i;
issrz::·iYP:
LOT
~x. IDENTIFICATION
PORTION
0;::p~::c?.:.."
LOT
IOE:NTIi=ICA
TIONCONSIGNEE
~
-billtdIudI i.I,.,.iv.d
.DELIVER
I
I
I
,III -.Hi,~t
,
I
I
I
I I
I
I
I I I
C~.\o(MOOI'if I O=S':.~IPi:ON

.TO

-- ••.•.•.•

O..1.TE

'.-HT

r.;;..:.,

?V
UNITS
RECEIVEO
ceOE
SIZE·
Nt:':
UNI7S
U111TS
CUNliS
OMl,t
COOESIZ::
PCcccx:n
- i'YilE
l"4Ei
CROSS
UNITS
'NEiCHT
WEICHT
No.
OF
:;NI-:-;:
t';~ITS
=:MM.
ile
CROSS
RECE'iVEO
'-A'EICHi
3Y
.:\EC·~
(SICN':'
i"l.!RE "EC:lVEO
REC::IVEO
~~~;:
SY
(SICN
CEo"T"'IC":'
iE
,~o.
CONTR.:.C7
iU,::
10
No.
011CE~TIFIC':'
,~Ei
'.vMS"EXST.l.'E
WEICHT
~1I0
ceOE
No.
,·~o. REC'O
!. 71il.E'J
,ITLEI
UNITS
UNJi"
=R-ICE'
.'1/0
~o.
C"O
UNITS
I.HVlr.:..il0N
CES7:N,l.T10N
Mll::S
NEi
.:.JlNOUNC::.IIENT
NET
SS
WEICHT
?v
'HEICHT
W::ICHi
C::.~TLl:1C:"I:
cm
:'0.
a.
CIIOSS
7R':'MS
OESiIN...\TION
NET
CR~SS
Y
c..:..=tR.
WEICHT
W;ICHT
Meo::
".It':ICHi"
CIN
&
SiATE:
SI4;:'~?!O
UNliS
';NITS.••-:-URE
..• OE:'
C::'Y
Fe:
c." .= ~S
.'1/ ::':"RR.
~ :iQ
S
...
S
CR.:.CE
=" ,.iJho/u
•.•.,,:.
OISPOSITION
DISPOSITION
NUMSER
NUMBER
S;:RVICINC
RCU71NG
•.e::MM.
Eov,p",ut.
I
eM:O'~er
PC

OTICE

H.t't"cn:

3

CONSICN;:

NSIC,'lEE

.,

;.=-- •• ,.

REe;:IPT

REC:IPT

~OR

~CR

Co.'"lftod;r:y

&;

C':'RR';."1

::Ilic •

-

,I

l'oiUl

I

,l.PPROVEO

- OM3

No.

056 0-0/'7'1

-

-

E:=::.'40.

S

~:H."t!:.

SICNEE

- - TO
- DELIVER
I NOTICE

_ .f..an:us

OOCX:ET
UNI,S
?y
ceDE
SIZE·
CONSIGNEE
TY?E
GROSS
UNITS
WEICHT
UNITS 0.RECEIVED
REceiVED
CNET
OMM.
CODE
SIZ:;"TYP:
PC
PC
UNITS
No.
OF
RE:;IVED
0.:..
7E
3Y
REC'~
(SIGNA
iURE
TmE)
CEilTlFICA
T~
CA"TE
REC'O
GROSS
WEIGHT
NET
C;~r;'lrIC':'
WEIGHi
7UNIOS
U~liS
; No.
:ic.
PORTION
EX
REC;IVED
UD
8Y
(SICNATURE
,In,,)
CROSS
~C
WEICHT
~o.
:iv.
NET
WEICMi
IIET
R~i:
'NEIGHT
WEICHT
ID N••
PRCGi'l..:.M
UNIOS
TR':'NS
UNITS
oESTI,'I':"ION
UN
UIlIT
Irs
WEICH,
MODE
PRICE
CITY
.•
ST':'TE
IDENTIFICATION
..• ., MI!.:S
CROSS
COIlTAACT
DESTlN"?y
iJOH
CEiiTIFIC.l
..••EICHT
TION
OF
iE
Oil
So.
'NHS~.
&
STATE
CODE
ANNOUNC;Io4E.~T
CROSS
W~ICHT
SIZE
SIZ;
- -TY?E
TYpe
U/1I7S
UNITS
o:lY
c~.'t
?OS
OR
i'~SPORTION
,I(/~
?S-:,ilJ,dIN\lli;"
.:.
r.'V.,~.
IIltc.iv.::l'
II I II.•.•
I1--'
IIi~"t
NUMBER
I-- :':'RR.
DIS?OSiTlON
MUMSER I
I
.~CU71NC
I.•ICOMIo4.
Tel'
0,12.,
I
EQl.Iip",.,,=.
IIDEL.~
I IOES:.~~~TlO~
CODE
I ?CI DIS?OSJilON
I

•ro..- •...:

S

anc
::::,l.O.,tCCJ7"'f

'1'\

?!'IOft.

rS":'

Commodiry

.
PAGE

O",i;

S;.RY:C:,~C

Offic.

FORM
.

I

C~;;;;:=R
_

APPROVEO

- OhlS

No. ass

0-Cl'77

I

.,

:)Ct"wun

4
REC;I?T

."Co .

City

?OR

.

~JL:,~.~
= ~~

V2NDOR - OR. PROCESSOR INVOICE I~=;I'~';':'
C.:l::?!e~

:1ud return "'i~

:::e: .::~ s:::~::::~:) I

requir~a su;:?orting dc:c:u:en:s i::::::edil:ely

l..:,': 0;: SriJ?M:N,

INIT. & NO.

CArt

OR TRUCK

Cl.!~.~7;7Y

LIC"NS"

I,.'~;:;',.,...---

~:-::,::.:::::;

::~ 1--=

c''''

:C=Ct,;C-:-:ONS ~OA. C.W•.•.t,.ITY OISCOUN7$,
,r7...:.::'i SHE:71

I.IC.UIOA'7=:O

--

.••.•.••.•. =:.."":

....:.-.' ..•.

.:..::

..:.

...

~::;~

""',c", ["

I
C'
':"::::;i~!-,';;"" ::=~.-= I:: ==-,.,,::=-

O":"lV'AC'::~. '::7':. II;

-

- -'

--

'-

....

"

-

"---'''--

-.'.~ (:;:'::-';7 -""'1.'1',:::

I:'
:M...:.i'lem.nr
how,ver
ocher

ral Agencies

wilhaut
;rnd

in ,ccordonce

15 u.s.e.

;$

SC.te

13 use

'ding

;$ m;de

in/orm"ion

71~:

it, ,Iigibility
reder;tl

L;tw

wilh

The

to enler

1001;

may not conduct or sponsor,

the

PriHcy

in/orm.tion

enforc~menc

Z66.~·1.3i, J71, 641; 651,

of domestic deliveries.

(Units) delivered

in good condition
Date

Signature
PRIVACY

lollowing

proof

will

Act

0/

be used

ACT

AND

I9H

(5 use

10

complete

PUB-LlC
552>1 and
tbe

:.,m$

BURDEN

:~e P.perwor~
01 • cantr"t

be delermined.
inlo 3 conrrocr wilh ecc :;nnat
igenc:ie~. an4 in r!spol'Z:t! ta i court m;tgistr:ue
1014.

IS use

714m;

.nd

JI

use H:9.

and a person is not required to respond

m.y

STATEMENTS

ihi$
or

in/orm.tion
admini:;tr:uive

be 3ppliclble

to a collection

ileduc:ion

Act

between
m.y

0/

vendor

be

1995, l$ ,m,nded.
ad

provid'd

tribun;l.

:0 the

of information

the

The

inlorm.rion

i~,

3u:narily

tor

ecc. Furnis~ing Ine requ,sted
10

olner

provisions

reque~[in9
in/armaria,

'g.ncies.
IRS, O.p.nment
crimin;1 ;n4 civil
[rlud

01

a/
.rHUC!S.

provid,d

unless it displays

a currently

valid OMB control

ber. Public reponing burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions,
:hing existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this
en estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Agriculture, Clearance Officer,
v[ (OMB No. 0560-0177), Stop 7630, Washington, D.C. 20250-7630 ..

'URi'i THIS COMPLETED

FOR.!'v{TO THE KA.NSAS CITY COMMODITY

OFFICE, 6501 BEACON DRlVE,

K.A.NSAS CITY, MISSOURI

>3-4676
NCNC:SCRL\1IN~71CN ST~T=:'A::NT

:i

':';ri::;I:ul'! (U!O':'l ;::ronibilS di:::-imi:::lic:1 i:'1 ~ft it; ,r:s:,;m: ~l1d :::ivitie: en t:\e ~a:i; =1 r::!. ::I~r. r:<1:1iQr.~1 :uiSi:'l. ge:2:er, reli;ion, 3g!. ::is;::til:/.
i:;1 ::eliel:, :e:!.:;,1 .:rie,,,:r
.•t:c:'l. tn: :n2:-il:JI af 13i':'1ily :::t::~. (Not JII ;:lr:::'1ibi[:~ ~:H~ :::Iy t: ~lf :r:qr:m:J
.:'H:.7:t: wiU1 di::.:ili:ie: w!'lQreG2ir~ :lter:u:iye melflS Ior
:u:lie:ti~i1 at ~r:gr:~
ir.br;,'i;ticn iSnille.
luge
;l:rinr. ludic:::e.
u:.l :!'Icul~ :::::HH:t VS::;~'$ i':'nG;1 C~ncer Jt iZO:) ;:c·zsoa (yci,: ;;::d iCO).

'.!.!.

ile

~~:;i:::'1~~:

z

:;:':':~I:in(

d

II! ::C:) ;:0-:;5':'

Jise:'i::'1jn~!icn.

r,,:i:e

writ!

LiSa.:.,

Cir!!c:~::r. O!!i,~ 01 Civil ~ir;ht:. ~Q=:n ~:S-W, Wl'ti::!!n
'!c:;u~1 c;;:u::.:nify ~r:TidH ~=d !m~l~y!!r,

:r iQOL USQA i: In

5uildin;.

r.:.QO

Inde;:en:!er.:e

..tTe:tt'll!.

S'N, WZ:..:2itlS:Otl,

D.C.

:0:50-S':'JO

01