WA-237 Order for Printing U.S. Warehouse Receipt Forms

This form is available electronically

Form Approved – OMB No. 0581-0305 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-237 U.S. DEPARTMENT OF AGRICULTURE (07-31-18) Agricultural Marketing Service

1. Mail or Fax to:

USDA-AMS-WCMD-LSCB Chief, License and Storage Contract Branch

ORDER FOR PRINTING U.S. WAREHOUSE RECEIPT FORMS

P.O. Box 419205 Stop 9148 Kansas City, Missouri 64141-6205 FAX: (844) 930-0174

2. FOR AMS ONLY

3. Order No.

A. Vendor name      

B. Contact Information      

     

4. License No.

5. Print:

     

Receipt Number

CCC Warehouse Code Number:

     

Control Number:

     

6. Name of Warehouse

7. Location of Warehouse

     

     

8. Name of Warehouse Operator (Legal Entity)      

9. Incorporated Under the Laws of State of: (If not incorporated, show “None.”)      

10. Quantity Wanted

11. Serially Numbered

12. Copies in Set (Excluding original)

13. Type Assembly Desired

FROM

TO

     

     

     

     

     

     

     

     

     

     

Note: Duplicate copy of UGRSA grain receipts will be fully printed on salmon paper. Record Copy (to remain in book) - White

14. Commodity to be Covered: (Check One)

Cotton Rice Grain Other (Specify):

     

15. Kind of Receipt: (Check One)

16. Insurance Statement: (Check One)

Bearer Order Non-Negotiable

Fully Insured (Standard Policy)

All Risk (Except War Risk)

Not Insured

17. Type of Receipt: (Check One)

Single Bale

Multiple Bale

UGRSA (Grain)

Special Form (Copy Attached) Standard (Type):

     

18. Overprint: (Check appropriate box(es) below.) (Red ink will be used unless otherwise specified.)

Licensed Weigher Not Graded on Request of Depositor Other (Specify exact wording):

     

19. Warehouse Rates in Lien Column? (Check One) YES NO If “YES”, specify exact wording:      

20. SHIP TO: (Specify exact Name and Address, Including Zip Code to which receipts are to be shipped.)

21. Remarks:

     

     

SHIP BY: (Method)      

22. FOR USDA USE ONLY

23.

When this order is filled please have contract printer send statement of charges. A check will be promptly forwarded.

A. Approved By

     

A. Name

     

(For U.S. Department of Agriculture)

(Licensed Warehouse Operator)

B. Signed

B. Date Approved

     

C. Date Signed

     

(MM-DD-YYYY)

(MM-DD-YYYY)

WA-237 (07-31-18) 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 by the warehouse operator to order negotiable or nonnegotiable receipt forms from the Warehouse and Commodity Management Division. 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 10 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 LICENSE AND STORAGE CONTRACT BRANCH AT THE APPROPRIATE ADDRESS AT THE TOP OF THIS FORM.
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.