WA-81 Rider to Warehouse Operator's Bond

This form is available electronically. Form Approved – OMB No. 0581-0305

WA-81 U.S. DEPARTMENT OF AGRICULTURE (xx-xx-xx) Agricultural Marketing Service United States Warehouse Act RIDER TO WAREHOUSE OPERATOR’S BOND (See Page 3 for the Privacy Act and Paperwork Reduction Act Statements)

1. FOR AMS USE ONLY

A. License Number      

B. Initials      

C. Rider No.      

D. Bond Number      

See Instructions before completion of Items 2(a) through 2(h) of this form.

2. This Rider is to be attached to and forms a part of the Warehouse Operator’s Bond executed by the

Principal: (a)

     

(Principal, Name of Legal Entity, Warehouse Operator) Proprietor Partnership Limited Partnership LLC Corporation

(b)

     

, at (c)

     

,

(State of Incorporation or Where Organized)

(Principal Place of Business (City))

(d)

     

, operating the following warehouse(s) for the storage of:

(Principal Place of Business (State))

(e)

     

(Agricultural Product(s))

And Surety: (f)

     

in favor of the United States of America and which was effective on and after (g)

     

(Date) (MM-DD-YYYY)

and whereby the above-mentioned parties are bound unto the United States of America, conditioned upon the faithful

performance of certain obligations of the Principal as a warehouse operator in conducting its (h)

     

(Kind of Warehouse)

     

warehouses located at (i)

     

(Warehouse Address)

under the provisions of the United States Warehouse Act (Pub. L. 106 - 472) (7 U.S.C. 241 - 256) (the Act), the regulations promulgated thereunder and licensing agreements; and

3. The Principal has been licensed as a warehouse operator under the provisions of the above-mentioned Act; and

4. It is agreed that the penal sum of the Bond is changed from (a) $

     

to (b) $

     

This change shall be effective on and after (c)

     

and shall not affect the rights and obligations

(Date) (MM-DD-YYYY)

of the parties under the Bond prior to such change with respect to default of the Principal before such date: Provided, however,

that the aggregate liability of the Surety for default of the Principal shall in no event exceed (d) $

     

.

5. The Bond as amended by this Rider shall continue in effect for the life of the Bond as provided therein; and, nothing contained herein shall amend, alter, or extend any of the provisions, conditions or other terms of the Bond except the change(s) identified as:

     

WA-81 (xx-xx-xx) Page 2 of 3

6.	Signed, Sealed and Dated this	     	.
		(Date) (MM-DD-YYYY)

7. Principal(s)
	Principal: (a)		     
	(Legal Entity Name)
	     
	(Legal Entity Name)
	By: (b)	     
		(Individual, Partners, General Partner, Corporate Officer)
	     
	(Individual, Partners, General Partner, Corporate Officer)
Witness to Signatures of Principal(s):
Witness: (c)				Witness: (e)
City and State: (d)      				City and State: (f)      

8. Certificate as to Corporate Principal
	I, (a)		     
			(Individual’s Name – Corporate Office Holder)
	certify that I am the (b)			     			of the
				(Office Held – Usually the Secretary)
	(c)	     
		(Corporation)
	     
	(Corporation)
named as Principal in the within Bond; that the person(s) who signed this Bond on behalf of Principal was or were then incumbent(s) in the position(s) shown above of this corporation, that I know his or her signature(s), and his or her signature(s) thereto is or are genuine; and that this Bond was duly signed, sealed and attested for and in behalf of this corporation by authority of its governing body.
8D. Signature of Secretary or Other Officer as above					8E. Date (MM-DD-YYYY)      

WA-81 (xx-xx-xx) Page 3 of 3

9. Surety
	Surety: (a)		     
	By: (b)	     
Witness to Signatures of Surety(s):
Witness: (c)				Witness: (e)
City and State: (d)      				City and State: (f)      

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 869, 7 CFR Part 1423, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used to amend an existing bond that warehouse operators have provided under the United States Warehouse Act.  The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act. 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 0581-0305. 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

Instructions For WA-81

RIDER TO WAREHOUSE OPERATOR’S BOND

Warehouse and Commodity Management Division, License and Storage Contract Branch, uses this form to amend an existing bond warehouse operators have provided under the United States Warehouse Act.

The bond is prepared by the License and Storage Contract Branch and sent to the warehouse operator for signature and forwarding to the warehouse operator’s insurance company for execution. Surety submits the original of the completed form in hard copy or facsimile to the Warehouse and Commodity Management Division, STOP 9148, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 844-930-0174, for acceptance and licensing.

Warehouse operators execute the document by signatures and then forward the form to their Surety for execution.

This form is provided for informational purposes only.