Free Microsoft Word - 20313 R4 - Indiana

LICENSE APPLICATION
State Form 20313 (R4 / 8-06) Approved by State Board of Accounts, 2005

INDIANA STATE DEPARTMENT OF AGRICULTURE

Indiana Grain Buyers and Warehouse Licensing Agency 101 West Ohio Street, Suite 1200 Indianapolis, Indiana 46204 Phone: (317) 232-1356 Fax: (317) 232-1362 www.IN.gov/igbwla

Section A:

Initial

Amendment; (if adding facility or capacity). Check " " only one.

LICENSE TYPE Check " " only one. Section B: Grain Bank ­ A company that stores only grain bank grain and purchases less than fifty thousand (50,000)
bushels of grain per year and has a storage capacity of not more than fifty thousand (50,000) bushels of grain. Warehouse ­ A company that stores grain and purchases less than fifty thousand (50,000) bushels of grain per year. Grain Buyer ­ A company that purchase annually at least fifty thousand (50,000) bushels of grain from producers, (which is not for the sole purpose of feeding the company's own livestock or poultry); offers deferred pricing, delayed payments, or contracts linked to the commodity futures or commodity options market in connection with grain purchases. (Includes firms licensed under the U.S. Warehouse Act).

OFFICE USE ONLY
File #: Transaction #: Check #: Initials:

Buyer/Warehouse ­ A company that operates both as a warehouse and as a grain buyer. Section C:
Name of business: d/b/a:

COMPANY INFORMATION

Individual in charge:

Title of individual in charge:

Address (location and mailing):

City, State, ZIP code: County: Phone number (Area code): FAX number (Area code):

COMPLETE IF APPLICABLE
CCC (UGRSA) code: U.S. Warehouse Act code (Federal code):

Section D:
Please check " " only one: Proprietorship Partnership "S" Corporation Fiscal year closing date:

FORM OF BUSINESS ORGANIZATION
Corporation (Regular) Cooperative Other, specify: __________________________________________ A reviewed level Financial Statement, prepared by a qualified accountant, is required and must be sent in with this application.

Section E:

FORMAL APPLICATION AND CERTIFICATION

I hereby make application for License for the company identified above, under the provisions of the Indiana Grain Buyers and Warehouse Licensing and Bonding Law, IC 26-3-7-1, et seq, amended. I understand and agree, as a condition to the issuance of such a license, to make my business premises, records and inventories available for inspection by the Indiana Grain Buyers and Warehouse Licensing Agency, and to cooperate and assist in such inspections. I affirm, under the penalties provided for in the law, that the information in this application is true and accurate to the best of my knowledge and belief. Typed or printed name of applicant: Signature of applicant: Date:

IGBWLA Director's approval:

Date of approval:

Continued on next page

Section F:
1). Licensing Fee (includes 1 facility): Enter application fee:

CALCULATION OF LICENSING FEES

GRAIN BANK:..................................................................... $ 250.00 GRAIN BUYER:................................................................... $ 500.00 WAREHOUSE and BUYER/WAREHOUSE: Less than 250,00 bushel storage capacity.................................. $ 250.00 250,000 thru 999,999 bushel storage capacity............................. $ 500.00 1,000,000 thru 10,000,000 bushel storage capacity...................... $ 750.00 Over 10,000,000 bushel storage capacity................................ $ 1,000.00 2). Number of facilities, less one included in the above fee: (List Indiana facilities on pages 3 & 4, Section J.) (2) 3). Multiply Line 2 by $50.00 4). Total of Lines 1 and 3: Make check payable to: Indiana Grain Buyers and Warehouse Licensing Agency

$

(1)

$ $ COMPUTATION OF NET WORTH REQUIREMENTS

(3) (4)

Section G:

1). Indiana law MINIMUM NET WORTH requirements are: Enter applicable Net Worth requirement: GRAIN BANK ­ only grain bank, 50,000 bu capacity and buys less than 50,000 bu................... $10,000.00 WAREHOUSE ­ only stores grain and buys less than 50,000 bu per year................................ $15,000.00 GRAIN BUYER ­ buys more than 50,000 bu per year, offers DP and contracts, no storage......... $10,000.00 BUYER/WAREHOUSE ­ Less than 1 million bushels of capacity or purchases......................... $15,000.00 1 million or more bushels of capacity or purchases............................ $50,000.00 See Section B, License Type, for more information 2). Total bushel storage capacity of all facilities. (To be listed on page 4). (Warehouse and Buyer/Warehouse applicants only). 3). Multiply Line 2 by ten cents (.10¢) 4). TOTAL: (Line 1 and Line 3) 5). Total number of bushels purchased last year. (Grain Buyer and Buyer/Warehouse applicants only). 6). Multiply Line 5 by five cents (.05¢) 7). TOTAL REQUIRED NET WORTH: Enter the larger of Lines 4 or 6. By July 1, 1999, all firms must meet this requirement and a Current Asset to Current Liability ratio of one to one (1:1). 8). Company's current NET WORTH (as of _______/_______/_______) from reviewed financial statement. 9). If your Net Worth is equal to or greater than the requirement, continue to Section H. IMPORTANT: Net Worth (Line 8) must be at least the minimum required (Section G, Line 1) to add the deficient amount to the bond. If the required Net Worth (Line 7) is greater than your Net Worth (Line 8), enter the deficiency here and in Section H, Line 8. (2)

$

(1)

$ $
(5)

(3) (4)

$ $ $

(6) (7) (8)

$ $
(2)

(9)

Section H:
1). Minimum Amount of Bond Required.

COMPUTATION OF BOND 10,000.00
(1)

2). Total bushel storage capacity of all facilities listed on page 4, Section K. (Grain Bank, Warehouse, and Buyer/Warehouse applicants only). 3). Multiply Line 2 by ten cents (.10¢)

$

(3)

3a). Total of Lines 1 & 3

$

(3a)

4). Total dollar amount paid for grain purchased from producers during last fiscal year. (Grain Buyer and Buyer/Warehouse applicants only). 5). Multiply Line 4 by ½ % (.005). 6). Enter the larger amount of Lines 1, 3a, or 5.

$

(4)

$ $ $ $ $
Form of bond? Surety Cash Deposit Letter of Credit

(5) (6) (7) (8) (9)

7). BOND REQUIRED: Enter the smaller of Line 6 or $100,000.00. (Companies applying for more than one license, bond not to exceed $500,000.00 for company.) 8). If the minimum Net Worth requirement is met, Net Worth deficiencies can be added to the bond requirement. Enter deficiency in required Net Worth from Section G, Line 9. 9). TOTAL BOND REQUIRED: Lines 7 plus Line 8. Carrier of bond, if known: License Application ­ Page 2

Section I:
A.

INSURANCE

Provide a Certificate of Insurance as evidence that you have an effective policy of insurance which: Insures, in your business name, ALL GRAIN in the facilities for which you are seeking a license from Indiana Grain Buyers and Warehouse Licensing Agency, for the full market value of that grain against loss by fire, internal explosion, lightning and windstorm, And...

B. Is issued by an insurance company authorized to do business in Indiana: (enter the name of insurer below). Name of insurer: Policy number:

Section J:
Name of facility: d/b/a: Individual in charge: Address (location and mailing): City, state, ZIP code: County: Capacity in bushels:

INDIANA FACILITY INFORMATION
File number:

Title of individual in charge:

Phone number (Area code):

FAX number (Area code):

Capacity calculated by ?

State Chart

Federal Chart

Company Computation File number:

Name of facility: d/b/a: Individual in charge: Address (location and mailing): City, state, ZIP code: County: Capacity in bushels: Phone number (Area code): Title of individual in charge:

FAX number (Area code):

Capacity calculated by ?

State Chart

Federal Chart

Company Computation File number:

Name of facility: d/b/a: Individual in charge: Address (location and mailing): City, state, ZIP code: County: Capacity in bushels: Phone number (Area code): Title of individual in charge:

FAX number (Area code):

Capacity calculated by ?

State Chart

Federal Chart

Company Computation

Additional Indiana Facilities continued on page 4
License Application ­ Page 3

Section J:
Name of facility: d/b/a: Individual in charge: Address (location and mailing): City, state, ZIP code: County: Capacity in bushels:

INDIANA FACILITY INFORMATION CONTINUED
File number:

Title of individual in charge:

Phone number (Area code):

FAX number (Area code):

Capacity calculated by ?

State Chart

Federal Chart

Company Computation File number:

Name of facility: d/b/a: Individual in charge: Address (location and mailing): City, state, ZIP code: County: Capacity in bushels: Phone number (Area code): Title of individual in charge:

FAX number (Area code):

Capacity calculated by ?

State Chart

Federal Chart

Company Computation File number:

Name of facility: d/b/a: Individual in charge: Address (location and mailing): City, state, ZIP code: County: Capacity in bushels: Phone number (Area code): Title of individual in charge:

FAX number (Area code):

Capacity calculated by ?

State Chart

Federal Chart

Company Computation

(If more than six Indiana facilities, please attach a separate list.) STORAGE CAPACITIES
1). Total Capacity of facilities listed on the application: 2). Total Capacity of facilities listed on attached list: 3). TOTAL Capacity of ALL facilities: (1) (2) (3)

The following MUST be received by the Agency before a license can be issued:
Application Check for License Fee Bond Reviewed Level Financial Statement Certificate of Insurance Please complete each section entirely and return the application with fees to: Indiana Grain Buyers and Warehouse Licensing Agency, 101 West Ohio Street, Suite 1200, Indianapolis, Indiana 46204 Make checks payable to: Indiana Grain Buyers and Warehouse Licensing Agency (IGBWLA)