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

This form is available electronically

Form Approved – OMB No. 0560-0120 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-237 U.S. DEPARTMENT OF AGRICULTURE (10-03-11) Farm Service Agency

1. Mail or Fax to:

Chief Licensing Branch

ORDER FOR PRINTING U.S. WAREHOUSE RECEIPT FORMS

P.O. Box 419205 Stop 9148 Kansas City, Missouri 64141-6205 FAX: (816) 926-1548

2. FOR FSA ONLY

3. Order No.

A. Vendor name      

B. Contact Information      

     

4. License No.

5. Print:

     

Receipt Number

CCC Warehouse Code Number:

     

Control Number:

     

6. Name of Warehouse

7. Location of Warehouse

     

     

8. Name of Warehouse Operator (Legal Entity)      

9. Incorporated Under the Laws of State of: (If not incorporated, show “None.”)      

10. Quantity Wanted

11. Serially Numbered

12. Copies in Set (Excluding original)

13. Type Assembly Desired

FROM

TO

     

     

     

     

     

     

     

     

     

     

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)

16. Insurance Statement: (Check One)

Bearer Order Non-Negotiable

Fully Insured (Standard Policy)

All Risk (Except War Risk)

Not Insured

17. 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) YES NO If “YES”, specify exact wording:      

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. Approved By

    

A. Name

     

(For U.S. Department of Agriculture)

(Licensed Warehouse Operator)

B. Signed

B. Date Approved

     

C. Date Signed

     

(MM-DD-YYYY)

(MM-DD-YYYY)

WA-237 (10-03-11) Page 2
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 by the warehouse operator to order negotiable or nonnegotiable receipt forms from the Kansas City Commodity Office. 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 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. 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 AT THE APPROPRIATE ADDRESS AT THE TOP OF THIS FORM.
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.