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

This form is available electronically.

Form Approved – OMB No. 0560-0120

WA-225 (10-03-11)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

1. Name and Location of Warehouse (City and State)

2. License and Code No.

WAREHOUSE OPERATOR’S STATEMENT AND EXAMINER’S COMPARISON OF OBLIGATED STOCKS

     

     

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 1423, 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 the warehouse operator’s statement and examiner’s comparison of obligated stocks. 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.

3. PAPER/CARD RECEIPTS ISSUED SINCE LAST EXAMINATION

4. UNISSUED RECEIPTS ON HAND

A. Beginning Number

B. Ending Number

C. Number Issued

A. Beginning Number

B. Ending Number

C. Number on Hand

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

D. TOTAL:

     

D. TOTAL:

     

5. Bonds Covering Lost or Destroyed Receipts (List on WA-101):      

6. Electronic Storage Obligations and Stocks on Hand:

A. Type (Electronic)

Receipts

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)

Receipts

B. Outstanding at Last Posted Date

C. Issued Since Last Cut-Off

D. Cancelled Since Last Posted Date

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

     

     

     

WA-225 (10-03-11) Page 2

11. Examiner’s comparison of Warehouse Operator’s obligations and inventoried stocks:

A. Total Stocks on Hand:

     

B. Cut-Off Date:

     

Unit Check Count

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 Items 13E and 13F where cotton stocks are covered by 100%, no-limit reporting form policy.

INVENTORY UNITS

A. Stocks

B. Insured

C. Not Insured

D. Total

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:

     

B. Others:

     

15A. If reporting form insurance is carried, when was last report submitted?

15B. Did report to insurance company correspond with warehouse records?

15C. If “NO”, explain:

     

     

YES NO

16. Insurance policies in effect which cover stocks:

A. Policy Number

B. Insurance Company

C. Expiration Date (MM-DD-YYYY)

Amount of Insurance

D. Fire

E. Extended Coverage

     

     

     

$

     

$

     

     

     

     

$

     

$

     

     

     

     

$

     

$

     

17. Number of Bales

18. Value Per Bale

19. Total Value

     

$

     

$

     

20A. Signature of Examiner

20B. Date (MM-DD-YYYY)

     

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.