Food Donation Programs (Food for Progress & Section 416(b)) and McGovern-Dole International Food for Education and Child Nutrition Program

OMB Control No. 0551-0035

See reverse side for Privacy Act, Public Burden and Nondiscrimination Statements. Form Approved - OMB No. 0560-0177

SURVEY COMPANY NAME

NAME OF SUBCONTRACTOR

PERSON(S) WHO PERFORMED SURVEY

SHIPMENT INFORMATION
VESSEL NAME/VOYAGE #		CCC REFERENCE NUMBER		DESTINATION COUNTRY
DISCHARGE PORT OR INLAND DESTINATION		VESSEL ARRIVAL DATE		VESSEL DISCHARGE COMMENCED/COMPLETED
DELIVERY TO FINAL DESTINATION COMMENCED/COMPLETED			DESTUFFING OF CONTAINERS COMMENCED/COMPLETED
COMMODITY/PACK SIZE		MANIFESTED UNITS		MANIFESTED WEIGHT (KGS/LBS)
SURVEY FINDINGS
DESCRIPTION	UNITS		ACCEPTED WEIGHT (Includes reconstituted/ sound KGS/LBS)		WEIGHT LOSS IN KGS/LBS (Includes unfit losses)
Quantity Discharged Sound
Torn/Slack/Leaking
Discharged Empty
Wet
Infested
Moldy
Other Unfit (i.e., contaminated/caked/ stained)
TOTAL QUANTITY DISCHARGED
Short Landed
Excess Landed
Sound/recovered Sweepings

Additional Comments

DOCUMENT CHECKLIST
Tally Sheets	3 day notice to Vessel or Agent of loss	Short Landing Certificate
Unfit Certificates/Lab Analysis	Confirmation of Attendance	Photographs

Disposition Documentation ( sold donated destroyed/dumped )

NOTE: If no documentation explain disposition in comments

PRINTED NAME OF PREPARER

KC-334 (REVERSE) Form Approved - OMB No. 0560-0177

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the information is 7CFR 1400, Subchapter C. The information will be used to evaluate bids to purchase processed commodities and provide services. Furnishing the requested information is voluntary; however, failure to furnish the requested information will result in nonconsideration. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided.

Federal agencies may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, 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

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program 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, genetic information, political beliefs, 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, Director, Office of Civil Rights, 1400 Independence Avenue, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.