U.S. USDA Form usda-kc-156
This form is available electronically.
KC-156
(9-28-82)
Form Approved - OMB No. 0560-0177
NOTE: The food products described below have had representative samples
examined by an authorized representative of the U. S. Department of
Agriculture, and were found to be acceptable under the terms and conditions
of the purchase announcement.
U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
EXPORT CERTIFICATION FOR
TITLE II COMMODITIES
No liability shall attach to the U. S. Department of Agriculture or to any officer or
representative of the Department with respect to this document.
1. NAME AND ADDRESS OF EXPORTER
2. COMMODITY REQUEST NO.
3. NUMBER AND DESCRIPTION OF PACKAGES
4. NET WEIGHT
5. NAME AND ADDRESS OF CONSIGNEE
6. PURCHASE INVITATION NUMBER
7. CONTRACT NUMBER
8. COMMODITY
9. PORT OF EXPORT
11. DESTINATION PORT
SIGNATURE
10. DISTINGUISHING MARKS
12. DESTINATION COUNTRY
13. VESSEL NAME
TITLE
Check applicable copy designation as shown below:
Original - Consignee
Green - Consignee Copy
Blue - Financial Operations Division
Pink - Issuing Office
DATE
Goldenrod - A.I.D.-Washington, D.C.
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. This document will be used as a
replacement for the phytosanitary certificate for certain commodities for which phyto-certificates are not issued. Furnishing the
requested document is required by a number of countries before food donations are allowed into their countries. Failure to
furnish the requested document may result in cargo being detained at entry into some countries. 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.
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 0560-0177. 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 to U.S. Department of Agriculture,
Kansas City Commodity Office (OMB No. 0560-0177), 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 programs and activities on the basis of race, color,
national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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).
USDA is an equal opportunity provider and employer.