Form KC-269 Notice to Deliver (Self Certification)

Web-based Supply and Chain Management System (WBSCM)

KC-269

WBSCM

OMB: 0560-0177

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-269
NOTICE
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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
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UN
CIS
COOE
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iE
Ot.i'E
No.
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:'i••
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CONTRACT
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i~t:.;'iS
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OR
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SIZE·
CONSIGNEE
TY?E
GROSS
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UNITS 0.RECEIVED
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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

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BURDEN

:~e P.perwor~
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1014.

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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

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vendor

be

1995, l$ ,m,nded.
ad

provid'd

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of information

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unless it displays

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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

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