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pdfFORM APPROVED OMB NO. 0580-0013
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 0580-0013. The time required to complete this information collection is estimated to average 5 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.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FEDERAL GRAIN INSPECTION SERVICE
REQUEST FOR WAIVER OF INSPECTION
TO:
FROM:
We hereby request a waiver of inspection for the lot identified below.
(An English written copy of the contract is attached.)
NAME OF VESSEL
CONTRACT NO
LOCATION OF SERVICE
APPROXIMATE DATE OF LOADING
DESTINATION
KIND OF GRAIN
QUANTITY OF GRAIN TO BE LOADED
CONTAINER MARKING
_____________________
(DATE)
__________________________________________
(NAME AND SIGNATURE)
__________________________________________
(TITLE)
FOR USDA USE ONLY
QUANTITY OF GRAIN LOADED
WAIVER APPROVED
WAIVER DENIED FOR THE FOLLOWING REASON(S): _____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________
(DATE)
___________________________________________
Form FGIS-941 (01/18) Previous editions are obsolete. Expires January 2021
(NAME AND SIGNATURE)
FIELD OFFICE MANAGER
(TITLE)
FORM APPROVED OMB NO. 0580-0013
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 0580-0013. The time required to complete this information collection is estimated to average 5 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.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FEDERAL GRAIN INSPECTION SERVICE
REQUEST FOR WAIVER OF INSPECTION
TO:
1
2
FROM:
We hereby request a waiver of inspection for the lot identified below.
(An English written copy of the contract is attached.)
NAME OF VESSEL
LOCATION OF SERVICE
APPROXIMATE DATE OF LOADING
7
CONTAINER MARKING
CONTRACT NO
3
5
DESTINATION
KIND OF GRAIN
8
4
6
QUANTITY OF GRAIN TO BE LOADED
9
10
11
_____________________
(DATE)
12
__________________________________________
(NAME AND SIGNATURE)
13
__________________________________________
(TITLE)
FOR USDA USE ONLY
15
QUANTITY OF GRAIN LOADED
14
WAIVER APPROVED
WAIVER DENIED FOR THE FOLLOWING REASON(S): _____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
16
__________________
(DATE)
17
_____________________________________________
Form FGIS-941 (01/18) Previous editions are obsolete. Expires January 2021
(NAME AND SIGNATURE)
FIELD OFFICE MANAGER
(TITLE)
Instructions for Completing FGIS-941
1.
Show the name of person who the letter is addressed to.
2.
Show the name of the person who is requesting the waiver.
3.
Show the name of the vessel for which the waiver of inspection is requested.
4.
Show the contract number for the lot of grain which the waiver is requested.
5.
Show the location of the elevator where the grain is to be loaded.
6.
Show the country of destination of the grain to be loaded.
7.
Show the approximate date the grain will be loaded.
8.
Show the type of grain to be loaded.
9.
Show the approximate quantity of grain to be loaded.
10.
Show any applicable markings of the containers.
11.
Show the date of the applicant’s signature.
12.
Show the name and signature of the applicant for the wavier of inspection.
13.
Show the title of the person signing the wavier of inspection.
14.
Show the actual quantity of grain that was loaded.
15.
Check the appropriate box. If the wavier is denied please include the reason(s) for denial.
16.
Show the date of the Field Office Manager’s signature.
17.
Show the name and signature of the Field Office Manager.
CONTACT INFORMATION:
Contact the field office responsible for the geographic area in which the service will be provided.
The signed form should also be mailed to this location.
For further information on Request for Waiver of Inspection:
Anthony Goodeman, Acting Director
Field Management Division
[email protected]
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |