WA-87 Receipt for Obligor on Return of Securities

This form is available electronically.

WA-87 Form Approved - OMB No. 0581-0305

(07-31-18)

U.S. DEPARTMENT OF AGRICULTURE

Agricultural Marketing Service

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 AGRICULTURAL

MARKETING SERVICE 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 0581-0305. 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 WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

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.

Instructions For WA-87

Receipt For Obligor on Return of Securities

The Warehouse and Commodity Management Division (WCMD) use this form when returning securities pledged on WA-83 Warehouse Operator’s Bond (For Eligible Securities) to the warehouse operator. The securities and the original copy of the power of attorney (voided) are returned to the warehouse operator at the same time. The warehouse operator signs and returns the form WA-87 in addition to the original copy of the Receipt for Eligible Securities Accepted as Security, WA-88, to WCMD.

The License and Storage Contract Branch (LSCB) prepares this form and sends it to the warehouse operator along with securities and the original copy of the power of attorney (voided) for signature and return of the original of the completed form in hard copy or facsimile and the original of form WA-88, Receipt for Eligible Securities Accepted as Security to the LSCB/WCMD, STOP 9148, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 844-930-0174.

This form is provided for information purposes only.