WA-400 Addendum to the Terms and Conditions of the Licensing/Pr

This form is available electronically.

Form Approved – OMB No. 0560-0120 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-400 (10-03-11)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency United States Warehouse Act

1. FOR FSA USE ONLY

A. License Number

B. Initials

ADDENDUM TO THE TERMS AND CONDITIONS OF THE LICENSING/PROVIDER AGREEMENT

     

   

2.

The undersigned licensed warehouse operator or approved provider under the United States Warehouse Act (the Act) and the Administrator of the Act now agree to the following amended and modified terms and conditions of the applicable licensing or provider agreement as set forth: (Furnish additional terms and conditions for Item 2 in Item 6 on Page 2 of this form.)

     

3.

This addendum amends and modifies the applicable licensing or provider agreement that forms a part of the license or agreement number:

(a)

     

for (b)

     

(Principal: Name of Legal Entity)

     

(Principal: Name of Legal Entity)

at (c)

     

and is effective on (d)

     

.

(City and State)

(Date) (MM-DD-YYYY)

4. Warehouse Operator or Provider

4A. Warehouse Operator or Provider

     

(Warehouse Operator or Provider: Name of Legal Entity)

4B. Signature of Warehouse Operator or Provider

4C. Title

4D. Date (MM-DD-YYYY)

     

     

5. Farm Service Agency

5A. Signature of Farm Service Agency Official

5B. Title

5C. Date (MM-DD-YYYY)

     

     

WA-400 (10-03-11) Page 2
6. Additional terms and conditions for Item 2 on Page 1.
     
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 735, 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 and modify the provisions of the standard licensing agreement with a warehouse operator or the standard provider agreement with a provider. 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 and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File.  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 0560-0120. The time required to complete this information collection is estimated to average 30 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 KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived from any public assistance program.  (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 to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.