WA-220 Examination Report

See Page 2 for Nondiscriminatory, Privacy Act and Public Burden Statements.

Form Approved - OMB No. 0560-0120

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

WA-220
(11-01-04)

1. CHECK ONE

ORIGINAL

EXAMINATION REPORT
2. LICENSE AND CODE

3. AMENDMENT

SUBSEQUENT

AMENDMENT

4. DATE OF LICENSE

5. CAPACITY

6. LICENSE POSTED

(MM-DD-YYYY)

Examiner's
Check

7. NAME OF WAREHOUSE OPERATOR

11. MAILING ADDRESS OF HEADQUARTERS OFFICE (Zip code)
(Include street address for express delivery)

8. NAME OF WAREHOUSE

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

9. MAILING ADDRESS OF WAREHOUSE (Including Zip Code)

13A. TELEPHONE NO.
(Include Area Code)

10. PRINCIPAL PLACE OF BUSINESS

13C. EMAIL ADDRESS (If Applicable)

13B. FAX NO. (Include Area Code)

14. INDIVIDUAL IN CHARGE (HOME ADDRESS AND HOME TELEPHONE NUMBER (Include Area code)

15. TYPE OF BUSINESS ENTITY

Partnership

Corporation

LLC

Individual

16. CORPORATION
A. CHARTER EXPIRES (Date MM-DD-YYYY)

B. FOREIGN CORPORATION PERMIT ISSUED BY

C. PERMIT EXPIRES (Date MM-DD-YYYY)

State of
A. TYPE OF PARTNERSHIP (General, limited, etc.)

17. PARTNERSHIP (List names below if not shown above)
B.

C.

D.

E.

F.

G.

18. INDIVIDUAL
B. HOME ADDRESS AND TELEPHONE NUMBER (Include Area Code)

A. NAME

19. LIMITED LIABILITY COMPANY
A. OPERATING AGREEMENT

B. ARTICLES OF ORGANIZATION
D. AUTHORIZED BY

C. AUTHORIZED TITLES FOR SIGNATURES (If applicable)

Operating Agreement

Articles of Organization

20. NAMES OF INDIVIDUALS AUTHORIZED TO SIGN WAREHOUSE RECEIPTS
A

21. NAME OF ELECTRONIC WAREHOUSE
RECEIPT PROVIDER

B

C

22A. DOES WAREHOUSE OPERATOR BLOCK
PILE? (If "YES", Go To Item22B).

YES

NO

22B. IS WAREHOUSE OPERATOR AUTHORIZED
TO BLOCK PILE? (If "NO" Issue WA-125)

YES

NO

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.

Page 2

WA-220 (11-01-04)
23. OUTSTANDING LICENSES ISSUED TO SAMPLERS AND WEIGHERS (Federally Licensed Houses Only)
A. NAME OF LICENSEE

B. SERVICE PERFORMED

C. LICENSE NO.

D. WHERE POSTED

Examiner's
Check

24. STATE OTHER RELATED BUSINESS INTERESTS OF WAREHOUSE OPERATOR OR KEY PERSONNEL

25. GIVE NAMES AND LOCATIONS OF OTHER WAREHOUSES OPERATED BY WAREHOUSE OPERATOR NOT COVERED BY
THIS LICENSE AND CODE IN THE SAME TOWN

26. STATE OPERATIONAL HOURS THAT THE WAREHOUSE IS OPEN EACH DAY - IF WAREHOUSE IS NOT TO BE OPEN EACH
BUSINESS DAY, WHAT PROVISIONS HAVE BEEN MADE TO RECEIVE AND DELIVER COTTON?

27. DOES WAREHOUSE OPERATOR HAVE ANY TYPE OF AGREEMENT WITH A FIELD WAREHOUSE COMPANY? IF "YES",
HAS THIS BEEN CLEARED WITH USDA? IF "NO", FURNISH A COPY TO KCCO EXAMINER.
YES

NO

28. DOES WAREHOUSE OPERATOR ISSUE OPEN YARD OR EMERGENCY YARD RECEIPTS?
YES
30A. EXAMINER'S INITIALS

29. TOTAL OPEN YARD CAPACITY

NO
30B. DATE (MM-DD-YYYY)

NOTE: The following statements are 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 Parts 735 and 1427.1081. 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 the Department of the 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; 15 U.S.C. 714m; 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 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the date
needed, and maintaining the data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR KANSAS CITY
COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, P.O. Box 419205, Kansas City, MO 64141-6205.