State Form 17284 (R4 / 9-15)
Approved by State Board of Accounts, 2015
One North Capitol Avenue, Suite 600
Indianapolis, Indiana 46204
Telephone: (317) 232-1360
Fax: (317) 232-1362
File number
INSTRUCTIONS: Attach a bank authorization to report earned interest.
Name of business City
County State Receipt number
Nature of entity (check “
” only one)
Proprietorship Partnership Corporation LLC Other, specify: __________________________________
Herewith deposits with the Director a cash deposit under the provisions of the Indiana Grain Buyers and Warehouse Licensing and Bonding Law
(IC 26-3-7, as amended, the “Act”) the sum of ________________________________________________________________________ dollars
$ be held as set forth in IC 26-3-7-10 and 824 IAC 2-4-4.
The condition of the above cash deposit is based upon the above business having made written application to the Director for either a Grain Bank,
Warehouse, Grain Buyer, or Buyer/Warehouse license.
The licensee shall faithfully perform the duties in conformity with the provisions of IC 26-3-7, and such obligations as said licensee may assume under
agreements with depositors or sellers of agricultural commodities, this cash deposit shall be held as provided herein, otherwise to be allocated and
distributed as provided herein.
1. For purposes of the allocation of this cash deposit, the determination as to whether the licensee has faithfully performed all of his obligations as
described above shall be made by the Director, after and upon a full hearing in which the licensee further does hereby agree to be firmly and finally
bound by such final determination. The Director’s determination shall be made in writing and shall include findings of fact, conclusions of law, and a
statement of the amount to be paid, if any, by the licensee and the party or parties to whom payment is to be made.
2. If the license shall expire without being renewed, is revoked, or terminates in any manner, this cash deposit shall be held and retained by the Director
for the purposes and claimants described in the Act and the rules promulgated thereunder for a period of not more than six (6) months form the date
upon which written notice of license termination is received by the Director; provided that (a) upon receipt of a verified statement from the licensee that
all storage accounts have been settled, and obligations and liabilities arising from the operation of the licensee’s business have been paid and
discharged, or (b) upon the filing of a surety bond as provided in the Act, the Director may, but is not required to, refund the cash deposit before the end
of the six (6) month period.
3. This cash deposit is is not in the form of cash, a cashier’s check or a money order.
(a) If this cash deposit is in the form of cash, a cashier’s check or a money order, the deposit shall be held in a special account with a state or
federally licensed institution. The Director shall have NO OBLIGATION or duty to seek or obtain interest on such account, but if such account
does bear interest it shall be added to the sum set forth above as an additional deposit. Upon request, amounts in excess of the required cash
deposit may be returned.
(b) If this cash deposit is not in the form of cash, a cashier’s check or money order, it is in the form of a:
In witness whereof, the aforesaid licensee has herewith set his hand and seal this _____________ day of ______________________________,
year of _________________ , upon which date the obligation and agreements hereunder shall be and become effective.
Signature of licensee
Name of witness
Signature of witness Date (month, day, year)
Receipt number ___________________________ received from the aforesaid licensee this ___________ day of ______________________________,
year of ________________ , the sum of __________________________________________________________________________________ dollars
($ __________________________), to be held and allocated, distributed, returned or otherwise disposed of as provided herein and in the Indiana Grain
Buyers and Warehouse Licensing and Bonding Law (IC 26-3-7, as amended).
Signature Title
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