WA-125ER Memorandum of Adjustments - Electronic Response

Form Approved - OMB No. 0581-0305

This form is available electronically. (See Page 2 for Paperwork Reduction Act Statements)

WA-125ER U.S. DEPARTMENT OF AGRICULTURE (07-31-18) Agricultural Marketing Service MEMORANDUM OF ADJUSTMENTS – ELECTRONIC RESPONSE	A. License No.	     
	B. Code No.	     
	C. Date of Exam	     
Continuation from WA-125, Memorandum of Adjustments:
13. Warehouse Operator's Report of Action Taken
     
USDA is an equal opportunity provider, employer, and lender.

WA-125ER (07-31-18) (Page 2 of 2)

14. This section must be completed when grain is purchased by the warehouse operator to regain a sufficient inventory balance to meet all storage obligations.
A. Date (MM-DD-YYYY)		B. Kind	C. Bushel Amount	D. Type Purchase 1/		E. Check Number 2/	F. Date Issued (MM-DD-YYYY)	G. Dollar Amount $	H. Purchased From
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
     		     	     	     		     	     	     	     
1/ New grain, warehouse receipts, open storage, other.						2/ If not paid, enter "Contract Number"
15. CERTIFICATION OF WAREHOUSE OPERATOR
The information contained in the "Warehouse Operator's Report of Action Taken" is, to the best of my knowledge and information, true and correct, and a complete statement of the actions taken. I understand that a false statement or representation herein or in any subsequent report, may subject me to criminal and civil action taken under the statues of the United States including 15 U.S.C. 714m and 18 U.S.C. 1001.
15A. Signature					15B. Title				15C. Date (MM-DD-YYYY)
					     				     
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 document the warehouse operator's report of action taken in response to examiner exceptions to the operation of the warehouse, commodity shortages, or other violations of the United States Warehouse Act or Commodity Credit Corporation contract found during a warehouse examination. 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 30 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.

Instructions For WA-125 ER

Memorandum of Adjustments – Electronic Response

Warehouse operators use this form [as an alternative to a paper response] to respond to exceptions made by the warehouse examiner during the examination of warehouse facilities. The warehouse examiner issues the original form WA-125 citing exceptions to operations or conditions found that violate either the United States Warehouse Act or one of the CCC Storage Agreements. This form is an optional method of explaining how the exceptions will be rectified and the warehouse brought into compliance. This form is an alternative to the return of a paper copy of the form WA-125 that has provision for responding on the reverse side.

Submit the original of the completed form in hard copy or facsimile to the Warehouse and Commodity Management Division (WCMD), STOP 9148, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 844-930-0174.

Customers who have established electronic access credentials with WCMD may electronically transmit this form to the WCMD. Features for transmitting the form electronically are available to those customers who would like to establish online access credentials with WCMD, follow the instructions provided at the USDA eforms web site.

Warehouse Operators prepare the form.

Warehouse Operator completes all items.

Fld Name / Item No.	Instruction
A License Number	Enter the United States Warehouse Act license number from form WA-125.
B Code No.	Enter the CCC code number from formWA-125.
C Date of Exam	Enter the date of the warehouse examination.
13 Report	Enter a narrative of the warehouse operator’s report of action taken to remedy the exceptions taken on form WA-125.
14	If warehouse operator purchases grain to regain sufficient inventory to meet storage obligations, the warehouse operator completes this section detailing the purchases.
14A Date	Enter the date of the purchase.
14B Kind	Enter the kind of grain purchased.
14C Bushel Amount	Enter the number of bushels of grain purchased.
14D Type of Purchase	Enter the type of purchase: (for example) New grain, warehouse receipts, open storage, etc. If not paid, indicate the contract number.
14E Check number	Enter the check number if the purchase was paid.
14F Date issued	Enter the date the check was issued.
14G Dollar amount	Enter the dollar amount of the purchase.
14H Purchased from	Enter the name of the seller of the purchase.
15A Signature	Enter the signature of the warehouse operator’s designated person. If you are mailing or faxing this form, print the form and manually enter your signature. If this form is approved for electronic transmission and you have established credentials with USDA to submit forms electronically, use the buttons provided on the form for transmitting the form to the USDA servicing office.
15B Title	Enter the title of the warehouse operator’s designated person.
15C Date	Enter the date of the warehouse operator’s designated signature.