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

This form is available electronically.

Form Approved – OMB No. 0581-0305 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-400 (07-31-18)

U.S. DEPARTMENT OF AGRICULTURE Agricultural Marketing Service United States Warehouse Act

1. FOR AMS 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. Agricultural Marketing Service

5A. Signature of Agricultural Marketing Service Official

5B. Title

5C. Date (MM-DD-YYYY)

     

     

WA-400 (07-31-18) 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 0581-0305. 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 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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

Instructions For WA-400

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

This form is used by the Warehouse and Commodity Management Division staff to alter the provisions of the standard Licensing Agreement with a warehouse operator or the standard Provider Agreement with a provider.

This form is generally prepared by the License and Storage Contract Branch (LSCB) and sent to the warehouse operator and its parent corporation for execution and submission of the original completed form in hard copy or facsimile submitted 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.

Generally prepared by the Warehouse and Commodity Management Division and provided to the warehouse operator or provider for signature of acceptance.

Items 1A through 3D are for AMS use only.

Fld Name / Item No.	Instruction
1A & B License Number…	Item 1A. Enter USWA license number. Item 1B. Enter the initials of the person creating the document.
2 Amended and Modified Terms and Conditions…	Enter the amended and/or modification of the terms of the agreement. For additional terms use item 6 on page two.
3(a) - (d) Addendum amends and modifies…	Item 3(a). Enter the License or Agreement Number. Item 3(b). Name of Legal Entity. This name is either the Warehouse Operator's Name or the Provider Agreement holder’s full legal name and type of organization. See examples below: Example 1: For a proprietor, enter, for example “Susan Doe.” Example 2: For a corporation, enter, for example, “Does, Inc.”, “a [state of incorporation ]corporation”. Example 3: For a general partnership, enter, for example “Letitia Doe, Frank Doe, Selma Doe, and James Doe, co-partners, trading as Doe Farms under the laws of [the State under whose laws the partnership is organized]” Example 4: For a limited partnership, enter, for example “Doe Farms Limited Partnership under the laws of [the State of organization and under whose laws you operate] Selma Doe, General Partner”. Example 5: For a limited liability company, enter, for example “Doe Farms, L.L.C., a [the name of the State under which organized] limited liability company”. Item 3(c ). Enter the Warehouse Operator’s location [city and State] or, in the case of a Provider, “ILB” for intentionally left blank. Item 3(d). Enter the effective date (MM-DD-YYYY) of the change.

Items 4A through 4D is completed by the Warehouse Operator or Provider

Fld Name / Item No.

Instruction

4(a) – (d) Warehouse Operator or Provider

Item 4(a). Enter the Warehouse Operator Name or Provider Agreement holder’s name. See Item 3(b) above. Item 4(b). Signature of person having the authority to bind the ware-house operator or provider in a legal contract. See examples of who can sign below: Example 1. For a corporation, a signature resolution must be on file or a signature resolution must be sent with the bond for execution. Example 2. Partnerships require signatures of all partners. Example 3. General partner signs for a limited partnership. Example 4. LLC signature is according to the organizing documents. Item 4(c). Enter the title of the signer. Item 4(d). Enter the date of signature.

Completed by AMS

Fld Name / Item No.	Instruction
5(a) – (c) AMS Signature, Title and Date	Item 5(a). Enter the signature of the authorized AMS official. Item 5(b). Enter the title of the authorized AMS official. Item 5(c). Enter the date (MM-DD-YYYY) signed.