State Form 20313 - License Application
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Indiana Grain Buyers and
LICENSE APPLICATION
Warehouse Licensing Agency
State Form 20313 (R5 / 2-10)
One North Capitol Ave, Suite 600
Approved by State Board of Accounts, 2010
Indianapolis, Indiana 46204
INDIANA STATE DEPARTMENT OF AGRICULTURE
Phone: (317) 232-1356
Fax: (317) 232-1362
Section A:
Initial
Amendment (if adding facility or capacity) Check “ ” only one.
Section B:
LICENSE TYPE
Check “ ” only one.
OFFICE USE ONLY
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.
File number:
Warehouse
– A company that stores grain and purchases less than fifty thousand (50,000) bushels of grain per
year.
Transaction number:
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
Check number:
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).
Initials:
Buyer/Warehouse
– A company that operates both as a warehouse and as a grain buyer.
Section C:
COMPANY INFORMATION
Name of business:
d/b/a:
Companies website address:
www.
Individual in charge:
Title of individual in charge:
Address (location and mailing):
Contact’s email address:
City, State, ZIP code:
County:
Telephone number (Area code):
FAX number (Area code):
COMPLETE IF APPLICABLE
CCC (UGRSA) code:
U.S. Warehouse Act code (Federal code):
Section D:
FORM OF BUSINESS ORGANIZATION
Please check “ ” only one:
Proprietorship
Corporation (Regular)
Partnership
Cooperative
“S” Corporation
Other, specify: __________________________________________
Fiscal year closing date (month, day, year):
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 (month, day, year):
IGBWLA Director’s approval:
Date of approval (month, day, year):
Continued on next page
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