Form WA-50 Application for License or Modification of License for t

Form Approved - OMB No. 0560-0120

WA-50

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

(08-01-03)

APPLICATION FOR LICENSE OR MODIFICATION OF LICENSE
FOR THE CONDUCT OF A PUBLIC WAREHOUSE
(Under the United States Warehouse Act (7 U.S.C. 241 et seq.))
The SECRETARY OF AGRICULTURE
Washington, D.C.
The undersigned warehouse hereby applies for a license or amended license to conduct a public warehouse.
NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following
information is 7 CFR Part 735. Furnishing the requested information is voluntary and no penalty will be imposed for failure to respond. However, a response is required in order to be considered
for a warehouse license (7 U.S.C. 242) and the decision as to the applicant's eligibility for a license must be made in part on the basis of the information provided. This information will not be
disclosed outside of the U.S. Department of Agriculture except as required by law to the Department of Justice and to the Department of Treasury. 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 U.S.C. 286, 287, 371, 641, 651, 1001, and 31 U.S.C. 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 0560-0120. 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.
RETURN THIS COMPLETED FORM TO KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION.

1. LOCATION OF WAREHOUSE (City, County or Parish and State)

2. AGRICULTURAL PRODUCT(S)
STORED OR TO BE STORED

3. LICENSE NUMBER

6. AMENDMENT ACTION

5. LICENSING ACTION
Original

4. TOTAL ESTIMATED CAPACITY UNDER NEW OR AMENDED
LICENSE: (Bu., bale, lbs., cwt. or as appropriate)

A. Add new space

Amendment

B. Delete presently licensed space

E. Estimated Additional Capacity

D. Amendment Number

C. Other

F. Estimated Deleted Capacity

G. Facilities, Bins, Warehouses being Added or Deleted: (Describe briefly)

The agricultural product to be stored and the licensed capacity of the warehouse when stated on the license issued as the result of this application will be as
defined and as determined under applicable licensing agreements.
7B. STATE UNDER WHOSE LAWS CREATED

7A. TYPE OF ENTITY
Individual

Partnership

Corporation

Other

Applicants NOT PRESENTLY LICENSED: Consideration of application will be expedited if copies of partnership agreement; certified articles of
incorporation; by-laws and foreign corporation permit; articles of organization and operating agreement for an L.L.C. are submitted with application.
8. APPLICANT'S INTEREST IN WAREHOUSE TO BE LICENSED, (E.G., OWNED, LEASED, ETC.)
Consideration of application will be expedited if copies of any leases are submitted with application.
9.

Applicants not presently licensed must submit a current financial statement in accordance with regulations.

10.

The applicant, as a condition to the granting of the license, agrees to comply with and abide by the terms of the Act and regulations as they may
relate to the applicant and upon the suspension, revocation or expiration of the license, to deliver all unissued licensed warehouse receipts to the
Deputy Administrator or representative thereof. Those receipts will be destroyed by the Department without liability to the warehouse operator one
year from the date of suspension, revocation or expiration of the license, if the applicant does not authorize destruction prior thereto.

11.

An inspection of the warehouse is hereby requested as specified in the Act and regulations. An advance deposit of estimated
fees must accompany the application, payable to Farm Service Agency for $
dollars.
NOTE: Application should be signed by a officer of the corporation in the case of corporations and all partners in the case of partnerships.

12. The statements made in this application are certified to be true to the best knowledge and belief of the applicant.
A. SIGNED THIS:

B. DAY OF

C. YEAR

12D. APPLICANT: Name of Corporation
Partnership, Proprietor, Etc.
12E. AUTHORIZED SIGNATURE:
12F. TITLE:

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.