Form KC-334 Preliminary/Final Discharge/Delivery Survey Summary

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

KC-334

U.S. DEPARTMENT OF AGRICULTURE

(12-19-16)

Form Approved - OMB No. 0560-0177
PAGE

Farm Service Agency

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

of
REPORT NUMBER

NAME OF SUBCONTRACTOR

PERSON(S) WHO PERFORMED SURVEY

VESSEL NAME/VOYAGE #

FEEDER VESSEL/VOYAGE #

OCEAN BILL OF LADING #

COMMODITY PO #

DESTINATION COUNTRY/CITY

DISCHARGE PORT

VESSEL ARRIVAL DATE

VESSEL DISCHARGE COMMENCED/COMPLETED

SHIPMENT INFORMATION

DELIVERY TO FINAL DESTINATION COMMENCED/COMPLETED DESTUFFING OF CONTAINERS COMMENCED/COMPLETED

COMMODITY/PACK SIZE

MANIFESTED UNITS

MANIFESTED WEIGHT (KGS)

SURVEY FINDINGS
DESCRIPTION

UNITS

ACCEPTED WEIGHT (Includes reconstituted/
sound KGS)

WEIGHT LOSS IN KGS (Includes unfit losses)

Quantity Discharged Sound
Torn/Slack/Leaking
Discharged Empty
Wet/Moldy/Other Unfit
Infested
TOTAL QUANTITY
DISCHARGED
Short Landed
Excess Landed
Sound/recovered
Sweepings

Additional Comments

PRINTED NAME OF PREPARER

PREPARER SIGNATURE

DATE

KC-334 (REVERSE)

Form Approved - OMB No. 0560-0177

(12-19-16)

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a – as amended). The authority for
requesting the information identified on this form is 7 CFR Part 1400, the Commodity Credit Corporation Charter Act (15 U.S.C.
714 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to evaluate the CCC-contracted
surveyor’s ability to submit bids to purchase processed commodities and provide services. 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-3, Consultants File. Providing the requested information is voluntary. However
failure to furnish the requested information will result in a determination that the CCC-contracted surveyor is unable to submit
bids to purchase processed commodities and provide services.
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 0560-0177. The time required to complete this information collection 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 the burden estimate (or to reduce)
or any other aspect of this collection 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
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the
USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from
discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation,
disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal
or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all
programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print,
audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600
(voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may
be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online
at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide
in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected].
USDA is an equal opportunity provider, employer, and lender.