WA-139 Certificate of Loss of Canceled Or Uncanceled Warehouse

This form is available electronically.

Form Approved – OMB No. 0560-0120 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-139 (10-03-11)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

1. Type of Warehouse Receipt(s) (Check One Below):

2. License Number

Canceled

Uncanceled

     

CERTIFICATE OF LOSS OF CANCELED OR UNCANCELED WAREHOUSE RECEIPT(S)

Negotiable

Nonnegotiable

3. Name of Warehouse

     

4. Warehouse Location (City and State as shown on License)

     

PART A – CANCELED WAREHOUSE RECEIPT(S)

IT IS HEREBY CERTIFIED THAT the warehouse receipt(s) identified below, issued by the undersigned warehouse operator operating under provisions of the United States Warehouse Act and the regulations thereunder, was lost or misplaced by said warehouse operator after issuance to and return by the undersigned depositor or owner of said receipt(s) and that after diligent search such receipt(s) cannot be found by said Warehouse Operator. The person signing below as depositor or owner witnesses these facts and acknowledges delivery of said product(s) by said warehouse operator. He or she further stipulates that on the date indicated herein he or she was the lawful owner of said warehouse receipt(s). Said warehouse operator agrees to save harmless any innocent third party in event of the reappearance of said lost warehouse receipt(s).

5. Receipt No.

6. Date Issued (MM-DD-YYYY)

7. Depositor or Owner

8. Product

9. Grade

10. Weight Gross or Net

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART B – UNCANCELED WAREHOUSE RECEIPT(S)

IT IS HEREBY CERTIFIED THAT the warehouse receipt(s) identified below, prepared by the undersigned Warehouse Operator operating under provisions of the United States Warehouse Act and the regulations thereunder, was lost or misplaced by said warehouse operator after prepared and prior to the delivery of the receipt(s) or the product(s) covered thereby to the undersigned depositor; and that after diligent search such receipt(s) cannot be found by said Warehouse Operator. The person signing below as depositor

or owner witnesses these facts and acknowledges receipt of a new warehouse receipt(s) Nos.

     

     

or delivery of said product(s) in lieu thereof. Said Warehouse Operator agrees to save harmless any innocent third party in event of

the reappearance of said lost warehouse receipt(s).

11. Receipt No.

12. Date Issued (MM-DD-YYYY)

13. Depositor or Owner

14. Product

15. Grade

16. Weight Gross or Net

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PART C - CERTIFICATION

Under penalty of perjury, I declare that I have examined the foregoing certificate and that to the best of my knowledge and belief, it is a true, correct, and complete statement.

17A. Name of Warehouse Operator (Legal Entity)

17B. Title

     

     

17C. Signature of Warehouse Operator

17D. Date (MM-DD-YYYY)

     

18A. Depositor’s or Owner’s Name and Address (Including Zip Code)

18B. Signature of Depositor or Owner

18C. Date (MM-DD-YYYY)

     

     

PART D – WITNESSES TO SIGNATURE

19A Name of Witness

19B Signature

19C Address

     

     

     

     

     

     

WA-139 (10-03-11) Page 2

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 1423, 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 identify paper warehouse receipts lost by warehouse operators either canceled or not canceled. 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.