WA-125ER Memorandum of Adjustments - Electronic Response

Form Approved - OMB No. 0560-0120

This form is available electronically. (See Page 2 for Paperwork Reduction Act Statements)

WA-125ER U.S. DEPARTMENT OF AGRICULTURE (10-31-11) Farm Service Agency MEMORANDUM OF ADJUSTMENTS – ELECTRONIC RESPONSE	A. License No.	     
	B. Code No.	     
	C. Date of Exam	     
Continuation from WA-125, Memorandum of Adjustments:
13. Warehouse Operator's Report of Action Taken
     
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.

WA-125ER (10-31-11) (Page 2 of 2)

14. This section must be completed when grain is purchased by the warehouse operator to regain a sufficient inventory balance to meet all storage obligations.
A. Date (MM-DD-YYYY)		B. Kind	C. Bushel Amount	D. Type Purchase 1/		E. Check Number 2/	F. Date Issued (MM-DD-YYYY)	G. Dollar Amount $	H. Purchased From
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
1/ New grain, warehouse receipts, open storage, other.						2/ If not paid, enter "Contract Number"
15. CERTIFICATION OF WAREHOUSE OPERATOR
The information contained in the "Warehouse Operator's Report of Action Taken" is, to the best of my knowledge and information, true and correct, and a complete statement of the actions taken. I understand that a false statement or representation herein or in any subsequent report, may subject me to criminal and civil action taken under the statues of the United States including 15 U.S.C. 714m and 18 U.S.C. 1001.
15A. Signature					15B. Title				15C. Date (MM-DD-YYYY)
					     				     
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 document the warehouse operator's report of action taken in response to examiner exceptions to the operation of the warehouse, commodity shortages, or other violations of the United States Warehouse Act or Commodity Credit Corporation contract found 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. 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.