Form Ccc 49 – Fill Out and Use This PDF

This form is available electronically.

(See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

CCC-49

U.S. DEPARTMENT OF AGRICULTURE

LEAVE BLANK – CCC USE ONLY

(04-19-19)

Commodity Credit Corporation

1. Warehouse Code No.

2. Master Code No.

APPLICATION FOR APPROVAL OF WAREHOUSE FOR

COTTON STORAGE AGREEMENT (CSA)

3. Name and Location of Warehouse Exactly as Printed and/or

4.

Mailing Address of Warehouse (Including Zip Code)

Shown on Warehouse Receipts

5. County in Which Warehouse is Located

6. Name of Warehouse Operator (Individual(s) or entity name)

7A. Name of Manager or Superintendent of Warehouse

8. Warehouse Telephone Number

9. Warehouse Fax Number

(Including Area Code)

(Including Area Code)

7B.

E-Mail Address:

10. IS/DOES WAREHOUSE:

YES

NO

11. WAREHOUSE IS OPERATED BY:

CHECK

A. Licensed under United States Warehouse Act?

A.

Individual

B.

Licensed by the State?

B.

Partnership

C. Operate gin and/or compress facilities?

C.

Corporation or Cooperative:

D.

Storage Capacity (Approved)

D.

Limited Liability Company (LLC)

E.

Other (Specify:)

12.If warehouse is operated by a corporation or cooperative association, give the names of all officers. If a corporation, also give the names of all principal stockholders.

Officers

Shares Held

Other

Shares Held

A. President, Member, or Individual

F. Principal Stockholder(s):

B. Vice-President or Member

C. Secretary or Member

D. Treasurer or Member

E. General Manager, Member or Like Officer

13. If a Partnership, give Names of Partners

14. Is it a Limited Partnership? (If

“YES,” attach

statement signed by all partners explaining

limitations.)

YES

NO

15. Warehouse Operator’s Identification of Each Warehouse Unit, its Location and Capacity (Attach schedule if necessary)

A. Unit Identity

B. Street Address and City, if Different Than Item 3

C. Capacity (Bales)

D. TOTAL:

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.

CCC-49 (04-19-19)							Page 2
	Are All Warehouse Units		YES	NO	16B.	If Any Units are Leased Give: (Attach schedule if necessary).
16A.
	Owned?				Unit Identity	Name of Lessor	Date (MM-DD-YYYY)
							Lease Expires
16C. Has Warehouse Operator a
	Renewal Option on Leased
	Unit(s)?

17.Is Any Section or Unit of Warehouse Located on Railroad

Siding Serviceable for Placement of Cars? (If “YES,” complete Item 18.)

18.Name of Railroad:

19A. Is a Local, State, or Federal Felony Court					19B.	If “YES,” Briefly Explain Nature of Case.
	Case Pending Against the Warehouse
	Operator or Responsible Official or
	Employee of the Warehouse?
		YES		NO
20. Name of Applicant’s Cotton Fire Insurance Underwriter						21. Does Applicant have Insurance on Cotton Commonly Known as
						Inland Marine All Risk Insurance?

22. The applicant agrees:

-receipts and bale tags shall not bear prefixes or suffixes:

-receipts, either paper or electronic, and bale tags shall not bear numbers which are identical to outstanding warehouse receipts;

-block receipts shall have a list of the gin bale tag numbers, representing the individual bales, attached;

-to provide a copy of the electronic warehouse receipt profile to CCC, if requested.

23.The warehouse must be open for business (receiving, delivery, and settlement) every normal business day for a period not less than six hours between 8 a.m. and 6 p.m. Business hours must be posted at the public entrance. In case the warehouse cannot be kept open as required, the name and telephone number of the person authorized to receive and deliver cotton must be posted at the public entrance.

During a normal 40 hour workweek the applicant can: (The warehouse operator agrees to load out the warehouse’s

24. approved capacity at the rate of 4.5 percent per week.)

A.Receive and place in storage (including all services incidental thereto)

B.Pick out, load, and ship

25.Other:

26.The applicant certifies that all statements made herein are true and correct and that the applicant will operate in accordance

with the terms and provisions of the CSA. This form must be signed by an authorized individual, i.e., corporate officer, partner or proprietor. A manager of a business cannot sign unless authorized by: a resolution of corporation’s board of directors; or a power of attorney furnished by an owner of the business.

27A. Name of Warehouse Operator (Legal entity name as shown in Item 6.)

27B. BY: (Signature)	27C. Title	27D. Date (MM-DD-YYYY)

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 1423, 7 CFR Part 1427, and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used by a warehouse

operator to apply for a Cotton Storage Agreement to store cotton owned by CCC or cotton pledged as security to CCC for marketing assistance loans. 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 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 a Cotton Storage Agreement to store cotton owned by CCC or cotton pledged as security to CCC for marketing assistance loans.

The authority for collecting the following information is Pub. L. 107-171. This authority allows for the collection of information without prior OMB approval mandated by the Paperwork Reduction Act of 1995. The time required to complete this information collection is estimated to average 1 hour 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: warehousing@usda.gov or THE WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, Beacon Facility, PO BOX 419205 STOP 9148, KANSAS CITY, MO 64141-6205.