KC334.pdf

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

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REPORT NUMBER

KC-334 U.S. DEPARTMENT OF AGRICULTURE

(01-04-07) Farm Service Agency Preliminary Final (Check One)

DISCHARGE/DELIVERY SURVEY SUMMARY

(For CCC Contracted Surveys)

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

PREPARER SIGNATURE DATE

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 programs 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.

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS