KC-0041 (2).pdf

See reverse for Privacy Act, Public Burden, and Nondiscrimination Statements. Collection involves 10 or less individuals; therefore, OMB clearance not required.

1. DATE KC-43 U.S. DEPARTMENT OF AGRICULTURE

(11-16-05) Farm Service Agency

BREAKBULK VESSEL LOADING OBSERVATION WORKSHEET

2. INSPECTOR NAME 3. COMMODITY

2a. LOCATION

2b. CITY 2c. STATE 2d. ZIP CODE

2e. TELEPHONE NO. (Including Area Code) 2f. FAX NO. 2g. EMAIL ADDRESS

4. VESSEL NAME 5. STEVEDORE

6. N/D NUMBER(S) 6a. N/D COMPLETE?

Yes No

7. CONTRACT NUMBER 7a. CONTRACT COMPLETE? 8a. LOADING COMMENCED 8b. LOADING COMPLETED

Yes No

Complete findings below.

9. CATEGORY HOLD 1 HOLD 2 HOLD 3 HOLD 4 HOLD 5 TOTAL

a. Damaged and Not Loaded

b. Damaged and Loaded

c. Damaged, Loaded and Removed

d. Repaired and Loaded

e. Total VLO Damage (Sum of a thru c minus d)

10. COMMENTS/REMARKS (Infestation, Dirt, Moisture, etc.)

11. NUMBER OF METRIC TONS AND/OR UNITS FOR THIS DAY (As Advised by Loading Facility)

CERTIFICATION AND ACKNOWLEDGEMENT

I certify that the information reported on this form is complete and accurate. This certification is executed with full knowledge of the provision of 18 U.S.C. 1001, which provides for a fine or imprisonment of not more than five years or both, for knowing and willfully making any materially false, fictitious, or fraudulent statement or representation, and with full knowledge of the provisions of 31 U.S.C. 3729, which imposes civil liability for any person who knowingly makes, uses, or causes to be made or used, a false record to get a false or fraudulent claim paid or approved by the Government.

The certification and acknowledgement is applicable to the services performed in accordance with the requirements of the USDA, Farm Service Agency Vessel Loading Observation contract.

12. OBSERVER NAME (Please print) 12a. OBSERVER SIGNATURE 12b. DATE

13. OCEAN CARRIER/LOADING STEVEDORE

REPRESENTATIVE (Please print)

13a. OCEAN CARRIER/LOADING STEVEDORE REPRESENTATIVE (Signature)

13b. DATE

KC-43 (REVERSE)

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The following statement is 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 15 USC 714. Submission of completed forms is a requirement of the terms of the contract between the Government and the Contractor.

Furnishing the information is not voluntary. Failure to provide all completed form(s) as required by the contract will preclude payment under the contract. 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.

This collection involves 10 or less individuals; therefore, it does not require Office of Management and Budget (OMB) clearance. 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. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing this burden estimate to U.S. Department of Agriculture, Kansas City Commodity Office, Chief, Planning and Analysis 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.