Form Tr Gr 11 – Fill Out and Use This PDF

GRAIN DEALER LICENSE APPLICATION

For the Year Ending August 31,

Mail check and application to:

Wisconsin Dept. of Agriculture, Trade and Consumer Protection Division of Trade and Consumer Protection

Producer Security Section - Grain PO Box 8911

Madison, WI 53708-8911

For Office Use Only

License No.

Date Issued:

Ch. 126, Subchapter III, Wis. Stats.

Legal Name:

Trade Name:

Type of Entity

Check One:

MAILING LOCATION:

Contact Person:

Address:

Primary Phone:

Email:

Individual

Corporation

LLP

LLC

Partnership

Cooperative

Other

State of Formation:

Fax:

Page 1.

Page 2.

Page 3.

Page 4.

Instructions for completing the Grain Dealer License Application

"Grain dealer" means a person who buys producer grain or who markets producer grain as a producer agent. "Grain dealer" does not include any of the following:

(a)A person who merely brokers a contract between a grain producer and a grain dealer without becoming a party to the contract, taking control of grain, or accepting payment on behalf of the grain producer.

(b)A person who merely buys or sells grain on a board of trade or commodity exchange.

"Procure producer grain in this state" means to buy producer grain for receipt in this state or to acquire the right to market producer grain grown in this state.

On the "Legal Name" line, if a sole proprietorship, put the individual's name; if a partnership, corporation, cooperative or other, put company's full legal name. "Trade Name" - complete this only if you are using a d/b/a different from the legal name. Mailing address is where you want all correspondence to be sent. Please enter type of business operation (corporation, etc.).

Please enter name, telephone, fax number, and email address of the person we should contact at the mailing address. Enter corporation or cooperative officers, partners, trustees or managers/members of an LLC (include titles).

Please complete a line for each location engaged in the business of buying or procuring grain from producers (as defined in Chapter 126, Subchapter III).

Enter applicant's fiscal year end.

Enter the dollar amount paid and bushel amount (including purchases through barter transactions and/or credits against account receivables) for grain procured from producers in your most recently completed fiscal year. Please indicate deferred payment purchases made in your most recently completed fiscal year. If you have no previous purchases from producers or have not completed a fiscal year since you began procuring grain in Wisconsin, then estimate the total amount expected to be paid to producers and bushel amount for grain procured during a full fiscal year.

Enter number of trucks used to haul producer grain in this state. (Put copy of grain dealer license in each truck.)

Complete Section B if a producer owns greater than 50% of both the farm selling the grain and the dealer who is buying the grain and wishes to have these purchases exempt from fund assessments and financial statement requirements. A Grain Dealer Default Claim Waiver must be filed with the application.

There is a non-refundable basic license fee of $25.00.

There is a supplementary license fee obtained by multiplying the number of bushels reported under s. ATCP 99.11 (the bushel amount you indicated for producer grain procured in this state during your last completed fiscal year or the bushel amount you estimated you will procure) by 0.1 cent per bushel, and rounding (up or down) the product to the nearest $100, except that the fee may not be less than $100 or more than $10,000.

Examples: Total bushels 459,459.59 bu. x $0.001 = $459.46, license fee due is $500.00.

Total bushels 220,140.00 bu. x $0.001 = $220.14, license fee due is $200.00.

For each additional location (in excess of primary location), there is an additional fee of $100.00.

There is a license surcharge of $500.00 for operating without a license, other fees and surcharges may also be applied for activities during unlicensed periods (see s. 126.11(4)(e), Wis. Stats.), if applicable.

Total the applicable fees (add lines a through d). Enter total amount due on line e.

The application must be signed by an officer of the applicant or the applicant, who certifies the accuracy of the information. A sole proprietor would sign himself or herself. An "officer" would include a partner in a partnership, a trustee in a trust or a manager-member in an LLC. The signature must be authenticated by a Notary Public who has taken the verification of the statement upon oath or affirmation. Also enter the title of the person who has signed the application, and enter the date signed.

ENCLOSE THE APPROPRIATE FEES/SURCHARGES (check or money order, payable to DATCP). Send application, fees/surcharges to:

Wisconsin Department of Agriculture, Trade and Consumer Protection

Producer Security Section-Grain

P.O. Box 8911

Madison, WI 53708-8911

This application applies to a Grain Dealer license.

IF YOU HAVE ANY QUESTIONS, PLEASE CALL Darlene Davidson (608) 224-4970.