FSA-409B Commodity (BIN) Measurement Service Request and Results

This form is available electronically.				Form Approved – OMB No. 0560-XXXX
FSA-409B U.S. DEPARTMENT OF AGRICULTURE (proposal 1) Farm Service Agency COMMODITY (BIN) MEASUREMENT SERVICE REQUEST AND RESULTS FORM				1. FARM NUMBER      	2. PROGRAM YEAR     					3. MEASUREMENT SERVICE ID      
				4. FARM LOCATION (OPTIONAL)      
5A. REQUESTER’S NAME AND ADDRESS (Includng Zip Code)      				6A. NAME AND ADDRESS OF PERSON TO CONTACT (Including Zip Code)      
5B. TELEPHONE NO. (Including Area Code)      				6B. TELEPHONE NO. (Including Area Code)      
PART A – SERVICE REQUEST (Completed by Producer)
7. KIND OF STRUCTURE		8. COMMODITY TYPE				9. NO. OF BINS
RECTANGULAR (CUBE) CYLINDER WITH CONE OTHER		     				     
		     				     
		     				     
		     				     
I have reviewed the request and hereby agree to pay the cost based on the hourly rate and mileage calculations.
10A. SIGNATURE OF PERSON MAKING REQUEST								10B. DATE (MM-DD-YYYY)      
11. SPECIAL INSTRUCTIONS      
PART B – RECORD OF MEASUREMENT SERVICE PERFORMED (RESULTS) (Completed by Employee)
12. BIN NO.			13. COMMODITY TYPE				14. ADJUSTED MEASURED QUANTITY/NET BUSHELS
     			     				     
     			     				     
     			     				     
     			     				     
     			     				     
     			     				     
15. TOTALS:							     
ALL required determination for this farm visit have been made in accordance with applicable procedures.
16A. SIGNATURE OF EMPLOYEE									16B. DATE (MM-DD-YYYY)      
17. REMARKS:      
NOTE:	The following statement is 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 following information is 7 CFR 718. The information will be used to fulfill the producer’s request for service. Furnishing the requested information is voluntary. Failure to furnish the requested information will result in no service. 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. 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 0560-0260. The time required to complete this information collection is estimated to average 15 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.
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