Fillable GRAIN LICENSE APPLICATION NEW RENEWAL Grain Warehouse Class (Illinois)

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GRAIN LICENSE APPLICATION NEW RENEWAL Grain Warehouse Class (Illinois)

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Illinois Department of Agriculture • Bureau of Warehouses
P.O. Box 19281 • Springfield, IL 62794-9281 •217/782-2895• TTY 866/287-2999 • Fax 217/524-7801
https://www2.illinois.gov/sites/agr/Consumers/GrainWarehouses
GRAIN LICENSE APPLICATION
NEW RENEWAL
Grain Warehouse Class I Class II
The Undersigned hereby makes application to the Illinois Department of Agriculture under the provisions of the "Grain
Code", Illinois Compiled Statutes, Ch. 240, par. 40/1-1 et seq., for a license to conduct either a Class I public grain
warehouse with the authority to issue both negotiable and non-negotiable warehouse receipts; or a Class II public grain
warehouse with the authority to issue only non-negotiable warehouse receipts.
Grain Dealer Regular Incidental (Under $100,000 and used in feed business)
The Undersigned hereby makes application to the Illinois Department of Agriculture under the provisions of the "Grain
Code", Illinois Compiled Statutes, Ch. 240, par. 40/1-1 et seq., for a license to engage in the business of buying grain
from producers.
Yes No We do regularly and continuously report our positions to the Commodity Futures Trading Commission.
Principal Place of Business (the principal mailing address where application is to be sent):
Legal Name of Company
DBA (Additional name legally authorized to do business as)
Additional Address (Building name, suite number, mail stop, etc.)
FEIN (Federal ID #):
E 911 Address (physical street location – required item)
Receive Grain for:
Purchase Storage
U. S. Postal Address (P. O. Box, etc.)
City
State
County
Zip Code
Contact Person
Fax Number
Contact’s Telephone Number
Company’s Telephone Number
Contact’s E-mail Address
Company’s Internet Site
Illinois Headquarters Location (if the same as the principal place of business just enter “SAME”):
Additional Address (Building name, suite number, mail stop, etc.)
E 911 Address (physical street location – required item)
Receive Grain for:
Purchase Storage
U. S. Postal Address (P. O. Box, etc.)
City
State
County
Zip Code
Location Manager: (or contact person for this location)
Location Telephone Number
Contact’s E-mail Address
Location Fax Number
SECTION A: Additional Locations where grain is or will be stored for others or purchased from producers.
If adding a new location, was this location licensed before No Yes. If yes, give name of company previously
licensing this facility_______________________________________________________
List each additional Illinois locations to be licensed (if additional space is needed please attach a separate sheet):
Additional Location 1:
E 911 Address
(physical street location is required)
U. S. Postal Address (P. O. Box, etc.)
Receive Grain for:
Purchase Storage
City
State
Zip Code
County
Location Manager: (or contact person for this location)
Location Telephone Number
Location Fax Number
Additional Location 2:
E 911 Address
(physical street location is required)
U. S. Postal Address (P. O. Box, etc.)
Receive Grain for:
Purchase Storage
City
State
Zip Code
County
Location Manager: (or contact person for this location)
Location Telephone Number
Location Fax Number
Additional Location 3:
E 911 Address
(physical street location is required)
U. S. Postal Address (P. O. Box, etc.)
Receive Grain for:
Purchase Storage
City
State
Zip Code
County
Location Manager: (or contact person for this location)
Location Telephone Number
Location Fax Number
Additional Location 4:
E 911 Address
(physical street location is required)
U. S. Postal Address (P. O. Box, etc.)
Receive Grain for:
Purchase Storage
City
State
Zip Code
County
Location Manager: (or contact person for this location)
Location Telephone Number
Location Fax Number
SECTION B: Trucks used in purchasing grain from producers.
List each truck requiring a certification (if additional space is needed please attach a separate sheet)
Year
Make
V.I.N. (Serial Number)
SECTION C: Officers and General Manager (if additional space is needed please attach a separate sheet)
Name:
President / Owner / Principal
Partner (Circle One)
Telephone # and Extension
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
County:
Zip Code:
Name:
General Manager
Telephone # and Extension
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
County:
Zip Code:
Name:
Vice President / Active Partner
(Circle One)
Telephone # and Extension
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
County:
Zip Code:
Name:
Secretary / Treasurer / Active
Partner (Circle One)
Telephone # and Extension
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
County:
Zip Code:
Name:
Secretary / Treasurer / Active
Partner (Circle One)
Telephone # and Extension
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
County:
Zip Code:
Name:
Registered Agent
Telephone # and Extension
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
County:
Zip Code:
SECTION D: General Organization
Ag-Coop Corporation (Type)_________ Individual Partnership Other (Specify) __________
(LLC, Sub-S, etc.)
Facility’s Principal Activities: Grain Dealer Grain Warehouse Feed Mill Terminal Trucker Dealer
Grain Processor Other _______________________
Note to All Applicants: Illinois Corporations must have a copy of their Articles of Incorporation on file with the Illinois Secretary of State. Foreign
corporations must have a Certificate of Authority on file with the Illinois Secretary of State to transact business in the State of Illinois. If a corporation is
doing business under another name other then the original incorporated name that DBA must also be registered with the Illinois Secretary of State. If a
partnership or individual is doing business as another name it must be filed with the County under the Assumed Names Act. If this applies to a new
applicant proof must be submitted with the application for license, or you will be licensed under the individual or partnership name only. The name on
your license is the name that must appear on your warehouse receipts.
SECTION E: Section E is to be completed by NEW Grain Warehouse License Applicants (Section E is NOT for
those renewing their current Warehouse license).
Applicant will store grain only for others Applicant will store company owned grain as well as for others.
Applying for a new CLASS II Warehouse License
Maximum amount of storage space to be allocated for storage operations: ______________ bu.
Total storage space available: ______________ bu.
Applying for a new CLASS I Warehouse License
Estimated storage capacity to be licensed: ______________ bu.
SECTION F: All License Applicants must complete the applicable items of this section. Information should
be as of fiscal year-end. (New applicants should estimate grain purchases for first fiscal year but other
items in this section need not be completed unless actual data is available).
CURRENT FISCAL YEAR-END _____________ (If a newly organized company, state what your fiscal year-end will be.)
List the Major grain commodity, which you propose to buy, handle, and/or store (one only) ___________________
Will Price Later Contracts be used? Yes No Undecided
Grain Purchases First time grain purchased from producers at an Illinois location (amount required from all Grain Dealers):
Corn Soybeans Wheat Other Total
Dollar Value $___________ $___________ $___________ $___________ $_____________
Number of Bushels ___________ ___________ ___________ ___________ _____________
Grain Inventory (Company owned at fiscal year-end)
Corn Soybeans Wheat Other Total
Dollar Value $___________ $___________ $___________ $___________ $_____________
Number of Bushels ___________ ___________ ___________ ___________ _____________
Below indicate the total number of bushels on which collateral warehouse receipts have been issued to secure a loan:
Number of Bushels ___________ ___________ ___________ ___________ _____________
Unrealized gains on forward contracts $______________________________(List only if not already included in inventory)
Grain Assets (Excluding inventory & related party) Grain Payable (Excluding related party)
Grain Receivables $________________ Grain Payable (less Price Later) $_________________
Price Later Shipped $________________ Price Later Received $_________________
Price Later Service Charges $________________ Unrealized Losses on Forward Contracts
(List only if not already included in inventory) $_________________
Storage, Drying & Handling $________________ Other $_________________
Balance in Margin Accounts $________________ Other $_________________
Other $________________ Other $_________________
Other $________________ Other $_________________
All Related Party Receivable All Related Party Payable
Name of Related Party Amount of Asset Name of Related Party Amount of Liability
______________________ $_________________ ______________________ $_________________
______________________ $_________________ ______________________ $_________________
______________________ $_________________ ______________________ $_________________
______________________ $_________________ ______________________ $_________________
______________________ $_________________ ______________________ $_________________
______________________ $_________________ ______________________ $_________________
______________________ $_________________ ______________________ $_________________
______________________ $_________________ ______________________ $_________________
Net Position (in bushels)
Corn Soybeans Wheat Other Total
Net Grain Long (Short) Position ___________ ___________ ___________ ___________ ___________
Grain Profits
Corn Soybeans Wheat Other Total
Grain sales $___________ $___________ $___________ $___________ $____________
Cost of grain sold $___________ $___________ $___________ $___________ $____________
Grain Profits $___________ $___________ $___________ $___________ $____________
SECTION: G Fees
Class I Warehouse License: Regular Grain Dealer License
New and Renewal New and Renewal
$200 $200
Class II Warehouse License Incidental Grain Dealer License
New and Renewal New and Renewal
$150 $150
Each Additional Location
$ 25
Each Truck Certificate
$ 25
SECTION: H Signature Section
This application must be completed for all new applicants and each renewal. This application must be
signed by the owner, if an individual, by one of the partners if a partnership, or by an officer of the
corporation or association.
__________________________________________________________________________________
NAME OF COMPANY
_________________________________ _____________________ ___________
SIGNATURE TITLE DATE
THE FOLLOWING DOES NOT APPLY TO BUSINESSES WITH FEDERAL EMPLOYER IDENTIFICATION NUMBERS.
Pursuant to 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's
Social Security Number, and the applicant shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in
complying with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the
applicant to contempt of court.
Are you more than 30 days delinquent in complying with a child support order? Yes No
(NOTE: If you are not subject to a child support order, answer "no.")
Applicant's Social Security Number is __________________________.
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection
therewith, and to the best of my knowledge, they are true, correct, and complete.
___________________________________________ ____________________________
Signature of Applicant Date
NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Illinois
Compiled Statues, Ch 240 par 10/0.01 et seq. Failure to provide this information shall prevent this form from being processed. IL 406-0129(2/05)
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BUSINESS PRACTICES INFORMATION
Since the last time this form was submitted, has there been any changes in regard to the following personnel and/or
business associates? If so, please indicate name(s) where applicable
POSITION
YES
NO
NAME
General Manager
Grain Merchandiser
Grain Accounting Staff
Commodity Broker (s)
Banker(s) and/or Lender(s)
Is your company currently a party to any grain contract litigation?
YES
NO
Does your company ship by rail and/or barge? If answered, yes, Please indicate the procedures
followed to record the transaction: beginning as the grain is loaded until payment received
YES
NO
Did your company trade rail and/or barge freight at any time during the year?
YES
NO
Are any of the following market programs offered to your customers?
YES
NO
Farmer Marketing Program
Option Based Flex Contracts (Min/Max, premium offer, etc)
Derivative Contracts (Revenue, yield, weather, etc)
Trade Option Contracts
Managed Hedging (Contracts priced according to recommendations of a market advisory service)
Accumulator Contracts
Please provide a copy of : Board resolution/ position limits/program summary if any of above “YES”
Indicate the total bushel amounts for each type of contract currently open: Fiscal year end ____ or Exam ____
PURCHASE
SALE
TYPE
BUSHEL AMOUNT
TYPE
BUSHEL AMOUNT
Price Later
Price Later
Basis
Basis
HTA
HTA
HTA (Rolling)
HTA (Rolling)
HTA (Multiple crop year)
HTA (Multiple crop year)
Min/Max Ratio
Min/Max Ratio
Revenue
Revenue
Swaps
Swaps
Cash Contracts with a
purchased options linkage
Cash Contracts with a
purchased options linkage
Cash Contracts with a sale
options linkage
Cash Contracts with a sale
options linkage
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GRAIN LICENSE APPLICATION NEW RENEWAL Grain Warehouse Class (Illinois)

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Completed 4 May 2021

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