Fill and Sign the Record Receipt Form

Warehouse Record of Receipt       (Name of Warehouse)       (Address of Warehouse) RECORD OF RECEIPT Received from:       . (Name of Deliverer) For account of:       . (Name of Owner) Location:       . (Name of city or other location) THIS IS NOT A WAREHOUSE RECEIPT Description of Goods Unit Quantity Unit Value as Declared by Storer Total (specify) (number) (number) (dollar amount) (dollar amount) (specify) (number) (number) (dollar amount) (dollar amount) (specify) (number) (number) (dollar amount) (dollar amount) Certification and Declaration. The undersigned, having all right, title, and interest to transfer the property described below, requests a       warehouse receipt for (Negotiable or Nonnegotiable) such goods be issued in the name of       and sent to (Name of Owner)       of       . (Name of Recipient) (Street Address, City, County, State, Zip Code) The undersigned certifies that all quantities, weights, measure, makes, and descriptions including but not limited to values as stated on this document are true and correct. Liability of       shall be limited to values as stated. (Name of Warehouseman) (Signature of Storer)       (Printed Name of Storer) Warehouse Record of Receipt Page 1 of 2 Warehouse Certification. Inspection having been made, goods listed in this record of receipt have been duly received in apparent good condition and the declarations of quantity, weights, descriptions, and value appear to be correct as stated by the Storer. Values are Storer's and Warehouseman disclaims all liability and responsibility for them.       (Name of Warehouse Company) By: (Signature of Agent)       (Printed Name of Agent) Warehouse Record of Receipt Page 2 of 2