KC-334 Preliminary/Final Discharge/Delivery Survey Summary

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See reverse side for Privacy Act, Public Burden and Nondiscrimination Statements.

KC-334

Form Approved - OMB No. 0560-0177
PAGE

U.S. DEPARTMENT OF AGRICULTURE

(01-04-07)

of

Farm Service Agency

Preliminary
Final (Check One)
DISCHARGE/DELIVERY SURVEY SUMMARY
(For CCC Contracted Surveys)

REPORT NUMBER

SURVEY COMPANY NAME
NAME OF SUBCONTRACTOR
PERSON(S) WHO PERFORMED SURVEY

SHIPMENT INFORMATION
VESSEL NAME/VOYAGE #

CCC REFERENCE NUMBER

DESTINATION COUNTRY

DISCHARGE PORT OR INLAND DESTINATION

VESSEL ARRIVAL DATE

VESSEL DISCHARGE COMMENCED/COMPLETED

DELIVERY TO FINAL DESTINATION COMMENCED/COMPLETED
COMMODITY/PACK SIZE

DESTUFFING OF CONTAINERS COMMENCED/COMPLETED

MANIFESTED UNITS

MANIFESTED WEIGHT (KGS/LBS)

SURVEY FINDINGS
DESCRIPTION

ACCEPTED WEIGHT (Includes reconstituted/
sound KGS/LBS)

UNITS

WEIGHT LOSS IN KGS/LBS
(Includes unfit losses)

Quantity Discharged Sound
Torn/Slack/Leaking
Discharged Empty
Wet
Infested
Moldy
Other Unfit (i.e.,
contaminated/caked/
stained)
TOTAL QUANTITY
DISCHARGED
Short Landed
Excess Landed
Sound/recovered
Sweepings

Additional Comments

DOCUMENT CHECKLIST

Tally Sheets

3 day notice to Vessel or Agent of
loss

Short Landing Certificate

Unfit Certificates/Lab Analysis

Confirmation of Attendance

Photographs

Disposition Documentation (
sold
donated
NOTE: If no documentation explain disposition in comments

destroyed/dumped )

PRINTED NAME OF PREPARER
PREPARER SIGNATURE

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DATE

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KC-334 (REVERSE)

Form Approved - OMB No. 0560-0177

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS
The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act
of 1995, as amended. The authority for requesting the information is 7CFR 1400, Subchapter C. The information will be used
to evaluate bids to purchase processed commodities and provide services. Furnishing the requested information is voluntary;
however, failure to furnish the requested information will result in nonconsideration. This information may be provided to other
agencies, IRS, Department of Justice, or other State and Federal Law enforcement agencies, and in response to a court
magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641,
651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided.
Federal agencies may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average
3 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. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S.
Department of Agriculture, Kansas City Commodity Office (OMB No. 0560-0177), Chief, Business Operations Support Division,
Stop 8768, P.O. Box 419205, Kansas City, Missouri 64141-6205.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program 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, genetic information, political beliefs, 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, Director, Office of Civil Rights, 1400
Independence Avenue, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is
an equal opportunity provider and employer.

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