WA-87 Receipt for Obligor on Return of Securities

This form is available electronically.

WA-87 Form Approved - OMB No. 0560-0120

(10-31-11)

U.S. DEPARTMENT OF AGRICULTURE

Farm Service Agency

RECEIPT FOR OBLIGOR ON RETURN OF SECURITIES

1. Name of Warehouse Operator

2. City

3. State

     

     

     

The undersigned hereby acknowledges receipt of the securities herein-after described, deposited with THE SECRETARY OF

AGRICULTURE as security in lieu of surety or sureties on UNITED STATES WAREHOUSE ACT BOND filed with the KANSAS CITY

COMMODITY OFFICE, for WAREHOUSE OPERATOR’S BOND. Said securities 1/ are registered in the name of

     

     

, and are assigned

     

.

4. Enter Applicable Name

5. In blank; to bearer; or to [identity of assignee); See 31 CFR Part 306.41.

A. Title of Securities

B. Coupon or Registered

C. Total Face Amount $

D. Denomination

E. Serial Number

F. Interest Dates

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

This receipt is executed in duplicate.

6A. Signature of Warehouse Operator/ Securities Owner

6B. Title

6C. Date (MM-DD-YYYY)

     

     

1/ This information to be furnished only in case of registered securities.

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 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 to return securities pledged on WA-83 - Warehouse Operator’s Bond (For Eligible Securities) to the warehouse operator. 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 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. 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.