Kc334_aj

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

KC334_AJ

OMB: 0551-0035

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OMB Control No. 0551-0035


Shape1 Shape2 See reverse side for Privacy Act, Public Burden and Nondiscrimination Statements. Form Approved - OMB No. 0560-0177


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SURVEY COMPANY NAME


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NAME OF SUBCONTRACTOR


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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

Shape12 Shape6 Shape7 Shape8 Shape9 Shape10 Shape11 Shape13 Shape14 Shape15 Disposition Documentation ( sold donated destroyed/dumped )

NOTE: If no documentation explain disposition in comments


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PRINTED NAME OF PREPARER


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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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePreliminary/Final Discharge/Delivery Survey Summary (bid form for CCC contracted surveys)
AuthorOrvilea
File Modified0000-00-00
File Created2021-07-11

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