U.S. USDA Form usda-kc-289
See reverse side for Privacy Act, Public Burden, and Nondiscrimination Statements.
FOR CCC USE ONLY
KC-289
U. S. DEPARTMENT OF AGRICULTURE
(9-11-03)
Farm Service Agency - Kansas City Commodity Office
1. DATE RECEIVED
2. TRANSMITTAL NO.
Post Office Box 419205 - Kansas City, Missouri 64141-6205
TRANSMITTAL FOR
COUNTRY AND TERMINAL WAREHOUSES
INVENTORY REDUCTIONS
AND INVOICE FOR RELATED CHARGES
3. WAREHOUSE CODE
4. LOADING ORDER NO.
Refer to Warehouse Operator's Handbook, Paragraph 80, 81 or 82 for Distribution.
5. NAME AND ADDRESS
6. DESTINATION
7. COMMODITY
SHIPMENT NO.
DATE OF
SHIPMENT
SHIPPED QUANTITY
SHIPMENT NO.
DATE OF
SHIPMENT
SHIPPED QUANTITY
8
9
10
8
9
10
11. NO. SHIPMENTS ON
12. TOTAL NO. OF
13. IS THIS A UNIT TRAIN SHIPMENT? (Ten or more cars per
THIS TRANSMITTAL
SHIPMENTS ON LOADING
ORDER, TO DATE
shipment)
YES b. Unit Train No. (
a.
14. NO. BUSHELS (OR
CWT.) ON THIS
TRANSMITTAL
17. FOR CCC USE ONLY
ACTION
)
c.
NO
16. DO THESE SH IPMENTS COMPLETE THE LOADING
CWT.) SHIPPED ON
ORDER?
LOADING ORDER, TO DATE
INITIALS
DATE
Input By
15. NO. BUSHELS (OR
a.
YES
b.
NO
Reviewed By
Corrected By
INVOICE FOR RELATED CHARGES
18.
19.
TYPE OF CHARGE
NUMBER
SHIPMENTS/WEIGHT
a.
b.
c.
d.
e.
20
21.
RATE PER UNIT
AMOUNT OF
CHARGE
Complete the following if charges are shown on this report.
I certify that the charges contained herein are correct and
that payment has not been received.
Weight
Inspection
Protein
Fumigation
f. TOTAL CHARGES ”
22. WAREHOUSE OPERATOR'S SIGNATURE
KC-289 (REVERSE)
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 following information is 15 U.S.C. 714b. Terminal and country
warehouse operators use this form for loading out CCC interest grain. This form also includes an invoice area for use by the
warehouse operator to bill CCC for the related charges in loading out grain. This information may be provided to other
agencies, Internal Revenue Service, 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 U.S.C.
286, 287, 371, 641, 651, 1001; 15 U.S.C 714m; and 31 U.S.C. 3729, may be applicable to the information provided.
The authority for collecting the following information is Public Law 107-171. This authority allows for the collection of
information without prior OMB approval mandated by the Paperwork Reduction Act of 1995. The time required to complete this
information collection is estimated to average 2 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.
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).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400
Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal
opportunity provider and employer.