WA-125 Memorandum of Adjustments

This form is available electronically. Form Approved - OMB No. 0560-0120

WA-125 U.S. DEPARTMENT OF AGRICULTURE (10-31-11) Farm Service Agency MEMORANDUM OF ADJUSTMENTS
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 735, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.).  The information will be used to document examiner exceptions to the operation of the warehouse, commodity shortages, or other violations of the United States Warehouse Act or Commodity Credit Corporation contract found during a warehouse examination and to document the warehouse operator's report of action taken. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act. 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.
1. Name of Warehouse      				2. License and/or Code Number      			5. Type of Exam Original Amendment Subsequent Special
3A. Location      		3B. County      				4. Date of Examination
						     
6. EXAMINER EXCEPTION (Continued on page 2)
An examination of this warehouse and the agricultural products stored therein disclosed the following conditions which must be corrected as soon as possible. The corrective action must be reported on the reverse of this form and mailed to the office shown in Item 12 within 15 days of the date you received this form. If all corrections are not completed within 15 days, you should report your progress at 15-day intervals until all corrections are completed. These conditions may also be in violation of various Federal or state criminal or civil statutes, program regulations, or your contract with the Commodity Credit Corporation. The issuance of this form is a report of the conditions found at this examination and is not an election by the United States or Commodity Credit Corporation of actions to be taken. Issuance of this form and compliance with the requirements herein by the Warehouse Operator do not and will not affect or limit the administrative, criminal, or civil action which the United States or Commodity Credit Corporation may take under criminal or civil statutes, the contract, or the program regulations:      
7A. Warehouse Examiner (Signature)					7B. Date Prepared (MM-DD-YYYY)
					     
I acknowledge receipt of this form.
8. Warehouse Operator      					9. By (Signature)
10. Date (MM-DD-YYYY)					11. Title
     					     
12. Report to be Submitted to:			Chief, Warehouse License and Examination Division Kansas City Commodity Office, FSA P.O. Box 419205 - Stop 9148 Kansas City, Missouri 64141-6205
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived from any public assistance program.  (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 to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.

WA-125 (10-31-11) Page 2 of 3

6. EXAMINER EXCEPTION (Continuation)

     

WA-125 (10-31-11) Page 3 of 3

13. WAREHOUSE OPERATOR'S REPORT OF ACTION TAKEN

     
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	B. Kind	C. Bushel Amount	D. Type Purchase 1/		E. Check No. 2/	F. Date Issued	G. Dollar Amount $	H. Purchased From
     	     	     	     		     	     	     	     
     	     	     	     		     	     	     	     
     	     	     	     		     	     	     	     
     	     	     	     		     	     	     	     
     	     	     	     		     	     	     	     
1/ New grain, warehouse receipts, open storage, other.					2/ If not paid, enter "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 statues of the United States including 15 U.S.C. 714m and 18 U.S.C. 1001.
A. Signature				B. Title					C. Date (MM-DD-YYYY)