WA-570 Inventory Adjustment Notice

This form is available electronically

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

WA-570 (10-03-11)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

1. Claim Number

2. Control Order Number

     

     

INVENTORY ADJUSTMENT NOTICE

3. Commodity Code

4. Storage Start Date (MM-DD-YYYY)

     

     

5. Program Code

6. Program Year

     

    

Rejection

Acknowledgment of Liability

Upward Adjustment

Short Shipment

7. Docket Code

     

12. Warehouse Operator’s Name and Address (Zip Code)

13. Warehouse Code      

8. Total New Weight

9. Total Gross Weight

     

     

     

     

10. Price Per Pound

11. Total Value

$

     

$

     

14. Warehouse Location

     

15. Identity of Original Shipment(s) and Quantity Rejected to Warehouse Operator

A. Commodity:      

B. Package Size:      

C. Lot Number

D. Inbound Order No.

E. Original No. of Units

F. No. Units Rejected

G. Net Lbs.

H. Shipper Name and Address (Including Zip Code)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

I. Reason for Rejection:

     

Note:

Disposition of the rejected commodity must be made in accordance with all local, State, and Federal law and regulations, including the Food, Drug and Cosmetic Act. All Government markings must be obliterated within 10 days and prior to disposition. Rejected containers shall be removed from USDA stocks within 10 days and set apart for final disposition.

16. The following checked short in the warehouse:

17. The following was shipped short from the warehouse:

A. Commodity:

     

A. Commodity:

     

B. Units:

     

C. Size:      

B. Units:      

C. Size:      

18. If Shipped, Short, Give:

A. Outbound Order Number      

C. Explain difference in ordered and shipped quantities:      

B. Shipping Date (MM-DD-YYYY)      

D. Is unshipped quantity available for future shipment?

E. If “NO”, Explain:      

YES NO

19. By Commodity Inspector:

20. By Warehouse Examiner:

A. Signature

B. Date (MM-DD-YYYY)

A. Signature

B. Date (MM-DD-YYYY)

     

     

21A. Receipt of rejected items and liability for loss and/or damage are hereby acknowledged.

21B. I certify that the commodity was shipped short as indicated above.

22A. Signature

22B. Title

B. Date (MM-DD-YYYY)

WAREHOUSE OPERATOR

     

WA-570 (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, 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 damage to Commodity Credit Corporation interest commodities identified during a warehouse examination. 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 and ineligibility to store and handle Commodity Credit Corporation interest commodities. 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.

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.