WA-51-2 Financial Statement Supplement

This form is available electronically

Form Approved – OMB No. 0581-0305

WA-51-2 U.S. DEPARTMENT OF AGRICULTURE (xx-xx-xx) Agricultural Marketing Service FINANCIAL STATEMENT SUPPLEMENT (For Agricultural Products)

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 file information for review in meeting financial reporting requirements 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 45 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 8758, P.O. BOX 419205, KANSAS CITY, MO 64141-6205. FOR OVERNIGHT DELIVERY, USDA-AMS-WCMD-LSCB, ATTENTION: FINANCIAL REVIEW, 2312 EAST BANNISTER RD., STOP 8758, KANSAS CITY, MO 64131-3011.

1A. Name (Corporation, Limited Liability Company, Partnership, or Individual’s Name)

2A. Address (Include Street, City, State, and Zip Code) (If applicable)

     

     

1B. Telephone Number (Area Code)

1C. FAX Number (Area Code)

2B. E-Mail Address

     

     

     

3. Statement Prepared By:

4. Form of Business:

Independent CPA Independent Public Accountant Other (Explain in Item 15)

Corporation (Co-op) Corporation (Reg) Corporation (Subchapter S)

Limited Liability Company Partnership Individual Proprietorship

5. Reserved

6. Fiscal Closing Date (MM-DD-YYYY)

7. Date of Entity Formation (MM-DD-YYYY)

     

     

8. ORGANIZATIONAL INFORMATION

(To be completed by Corporation, Limited Liability Company, Partnership, and Individual Proprietorship.)

Shares of Stock Held

A. Name of President, Member, Partner, or Individual

Home Address (Zip Code) and Telephone Number (Area Code)

     

     

     

B. Name of Vice President, Member, or Partner

Home Address (Zip Code) and Telephone Number (Area Code)

     

     

     

C. Name of Secretary, Member, or Partner

Home Address (Zip Code) and Telephone Number (Area Code)

     

     

     

D. Name of Treasurer, Member, or Partner

Home Address (Zip Code) and Telephone Number (Area Code)

     

     

     

E. Name of General Manager, Member, or Like Officer

Home Address (Zip Code) and Telephone Number (Area Code)

     

     

     

9. DIRECTORS OF CORPORATION (Attach additional sheet if more room is needed)

A. Name

B. Occupation

C. Home Address

D. Shares of Stock Held

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

WA-51-2 (xx-xx-xx) Page 2

10. All banks where Warehouse Operator obtains banking services:

A. Name of Bank

B. Location of Bank

C. Telephone Number (Including Area Code)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

11. Do you have a line of credit?

NO YES (If “YES”, list name and address of lending agency)

A. Name of Lending Institution

B. Address of Lending Institution

C. Amount of Line Credit

     

     

$      

     

     

$      

12. Who is the beneficiary of the cash value life insurance policy?

     

13.

Insurance Amount of Fire Insurance coverage (Give dollar values)

Amounts shown here must apply to corresponding assets shown on the balance sheet

A. Buildings

B. Fixtures and Equipment

C. Total

D. Vehicles – Rolling Stock

$

     

$

     

$

     

$

     

14. Inventory – Limit of Liability

Provisional Stock Specific

$

     

15. Remarks: (Use this space to furnish additional information needed to clarify any of the above statements. If more space is needed, attach additional sheets.)

     

16. CERTIFICATION

Under penalty of perjury, I declare that I have examined the enclosed financial statement, including any attachments, and it is a true, correct, and complete statement of the financial conditions of the above-named Warehouse Operator as of the date shown on the attached balance sheet and that the information contained in the Financial Statement Supplement is true and correct.

A. Name of Warehouse Operator (Legal Entity)

B. Warehouse Operator’s Signature

     

C. Title (Officer, Member, Partner, Proprietor)

D. Date Signed (MM-DD-YYYY)

     

     

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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

Instructions For WA 51-2

FINANCIAL STATEMENT SUPPLEMENT

Warehouse operators use this form to file information for review by the Financial Review Branch in meeting the financial reporting requirements for the United States Warehouse Act and the Commodity Credit Corporation Storage Agreements.

Submit the original of the completed form in hard copy or facsimile to the License and Storage Contract Branch (LSCB), ATTN: Financial Review STOP 8758, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 877-217-1945. Customers who have established electronic access credentials with LSCB may electronically transmit this form to LSCB. Features for transmitting the form electronically are available to those customers with access credentials only. If you would like to establish online access credentials with USDA, follow the instructions provided at the USDA eForms web site.

Warehouse Operator applicants and annual reporters must complete Items 1 through 16.

Fld Name/ Item No.

Instruction

1 Name

1A. Enter the warehouse operator’s full legal name. See Examples below: Example 1: For a proprietor, enter, for example, “Susan Doe”. Example 2: For a corporation, enter, for example, “Doe, Inc.” Example 3. For a general partnership, enter, for example “Letitia Doe, Frank Doe, Selma Doe, and James Doe, co-partners, trading as Doe Farms” Example 4. For a limited partnership, enter, for example “Doe Farms Limited Partnership, Selma Doe, General Partner” 1B. Enter warehouse operator’s telephone number as XXX-XXX- XXXX. 1C. Enter warehouse operator’s fax number as XXX-XXX-XXXX.

Fld Name/ Item No.	Instruction
2 Address	Enter the applicant’s complete mailing address and email (if applicable).
3 Statement Prepared by	Check the box that describes the person who prepared the accompanying financial statement.
4 Form of Business	Check the box that describes the nature of the organization of the applicant or reporting entity.
5 Reserved	Leave blank.
6 Fiscal Closing Date	Enter the date of the fiscal year close (month, day, year).
7 Date of Entity Formation	Enter the date of entity formation. In the case of a corporation that is the date of incorporation. In the case of a partnership, enter the date the agreement was signed. In the case of an LLC, enter the date documents were filed with the secretary of state. Do not complete if a proprietor.
8 A - E Organizational Information	8 A-E. For a corporation: Enter the name of each officer and the general manager where indicated, their home address, their home phone number, and the total number of shares of stock owned. For a limited liability company: Enter the name of each member, their home address (if an individual) or office address (if a corporation or entity other than individual). For a partnership: Enter the name of each of the partners, their home address (if an individual) or office address (if a corporation or entity other than individual). For a proprietor: Enter the name, home address and phone number of the individual.
9 A-D Directors of Corporation	9A. Enter the name of each of the directors of a corporation. 9B. Enter the occupation of each of the directors of a corporation. 9C. Enter the home address of each of the directors of a corporation. 9D. Enter the number of shares of stock held for each of the directors of the corporation.
10 A-C All Banks (etc.)	Enter the name of each bank used by the applicant or reporting entity, its mailing address, and telephone number where indicated. 10A. Enter the name of the bank. 10B. Enter the complete location address of the bank. 10C Enter the complete phone number of the bank including the area code.
11 A-C Do you have a line of credit?	Enter "X" or checkmark in the appropriate box the fact of a line of credit. 11A. If “YES” enter the name of the lending institution with whom the applicant or reporting entity has a line of credit. 11B. Enter the complete mailing address of the lending institution in Item 11A. 11C. Enter the amount of the line of credit of the lending institution in Item 11A.
12 Who is (etc.)	Enter the name of the beneficiary of any cash value life insurance.
13 A - D Insurance	13A. Enter the dollar value of limits of insurance covering the buildings that are on the accompanying balance sheet. 13B. Enter the dollar value of limits of insurance covering the fixtures and equipment that are on the accompanying balance sheet. 13C. Enter the dollar values of limits of insurance covering the total fixed assets that are on the accompanying balance sheet. 13D. Enter the dollar values of limits of insurance covering the vehicles or rolling stock that are on the accompanying balance sheet.
14 Inventory	Enter the limit of liability of insurance on inventory and check the box the nature of that insurance, whether provisional stock reporting policy or specific limit insurance policy.
15 Remarks	Enter any information needed to interpret or clarify the financial information presented.
16 Certification	16A.Warehouse Operator – Enter the name of the applicant 16B Enter the signature of the applicant.   16C. Title – Enter the business title of the individual applicant or reporting entity. 16D. Enter the date of signature (mm, dd, yy) BE SURE TO INCLUDE A FINANCIAL STATEMENT.