CCC-21 Declaration of Eligibility to Recieve Storage Paymentys

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This form is available electronically.

CCC-21

1. Current Crop Year

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation

(08-28-03)

2. Type of Storage Agreement:

SUPPLEMENT TO COMMODITY CREDIT CORPORATION (CCC)
STORAGE AGREEMENTS
Highly Erodible Land and Wetland Conservation
DECLARATION OF ELIGIBILITY TO RECEIVE STORAGE
PAYMENTS UNDER A CCC STORAGE AGREEMENT

NOTE:

3. CCC Agreement No.(s):

Cotton Storage Agreement
(CSA)
Peanut Storage Agreement
(PSA)
Processed Commodities
Storage Agreement (PCSA)
Sugar Storage Agreement
(SSA)
Uniform Grain and Rice
Storage Agreement (UGRSA)
Other:

The authority for collecting the following information is Pub. L. 108-7. 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 15 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.
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a). The authority for requesting the following information is 15 U.S.C. 714 and
regulations promulgated thereunder (7 CFR Parts 1421, 1423, 1427 and 1403). The information will be used to complete the terms of an agreement between the
warehouse operator and CCC. Furnishing the requested information is voluntary, however, without it, eligibility to enter into an agreement with CCC cannot be
determined. 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; 1014, 15 USC 714m;
and 31 USC 3729, may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE, P. O. BOX
419205, KANSAS CITY, MO 64141-6205.

INSTRUCTIONS TO WAREHOUSE OPERATOR: Complete Items 1 through 6 by entering the required information.
4. COMPANY NAME AND MAIN LOCATION IN THE STATE FOR THE APPLICABLE STORAGE AGREEMENT.
(Company name on Storage Agreement MUST be shown on AD-1026 as producer, if applicable.)

5. SOCIAL SECURITY NO. (or TAX ID NO.)

6. WAREHOUSE CODE(S)

INSTRUCTIONS TO WAREHOUSE OPERATOR: Complete Items 7 and 8 to determine if highly erodible land and wetland conservation
certification is necessary.
7.

If the warehouse operator has an interest in a farm as owner, operator, tenant, or sharecropper, complete Items 7 through 9, and file form AD-1026
with AD-1026A's at your local Farm Service Agency (FSA) office or service center. Contact the local FSA office or service center for filing instructions.
If the warehouse operator or any affiliated person from Item 8 has no farming interests, enter ''NONE'' in Item 7A and sign in Item 10.
Note: Failure to complete this Item 7 can lead to loss of storage payments under your CCC storage agreement.
LOCATION OF FARM

A.
STATE

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B.
COUNTY

C.
FARM NUMBER(S)
(If applicable)

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CCC-21 (08-28-03) (Page 2)
8.

Determine affiliated person(s) according the following chart. File form AD-1026 with AD-1026A's for all affiliated persons with farming interests with the
local FSA office or service center. In the following table, list affiliated persons in column A and the required information in columns B and C. Attach
additional sheets if necessary.
Note: Failure to complete this Item 8 can lead to loss of storage payments under your CCC storage agreement.

DETERMINING AFFILIATED PERSONS

IF the warehouse
operator is a(an)...

THEN affiliated persons who must file AD-1026 if they have farming interests are . . .

individual

spouse or minor children with separate farming interests, or who receives benefits under their
individual ID number.
estates, trusts, partnerships, and joint ventures in which the individual filing, or the individual's
spouse or minor children have an interest.
corporations in which the individual filing or the individual's spouse or minor children have more than
20% interest.

general partnership

first level members of the entity

limited partnership

Example: If the warehouse operator is Partnership A, and the partners are Trust A and Individual A, the
first level members of Partnership A are Trust A and Individual A.

joint venture
estate
irrevocable or revocable trust
Indian tribal venture or group
corporations with stockholders

first level members with more than 20% interest in the corporation.

State

none

Church or other charitable
organizations
county
city
public schools
corporations with no
stockholders
A.

B.

NAME OF AFFILIATED PERSONS

SOCIAL SECURITY OR
TAXPAYER ID NO.

C.

FARMING INTEREST
YES

NO

9. CERTIFICATION: I declare that Form AD-1026 and AD-1026A have been filed at the appropriate County FSA Office(s) or service center(s) for
the company and all affiliated persons and that the company and affiliates have not been declared ineligible to receive USDA benefits. I certify that
all information submitted to USDA on this form and Form AD-1026 and AD-1026A is true and correct.
A. SIGNATURE OF AUTHORIZED COMPANY REPRESENTATIVE

B. TITLE

C. DATE (MM-DD-YYYY)

INSTRUCTIONS TO WAREHOUSE OPERATOR: Sign the above certification if you have completed Items 7 and 8. If you entered ''NONE'' in Item 7, sign
the certification below.

10. CERTIFICATION: I hereby certify that the company or any affiliated person does not have an interest in any farm as owner, operator, tenant, or
sharecropper and the company or affiliated persons are not required to certify on Form AD-1026 to receive USDA loans or other program benefits
as a producer of agricultural commodities on highly erodible lands or converted wetlands.
A. SIGNATURE OF AUTHORIZED COMPANY REPRESENTATIVE

B. TITLE

C. DATE (MM-DD-YYYY)

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.

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