U.S. USDA Form usda-kc-1622
KC-1622
(10-22-03)
1. STORAGE AGREEMENT AND/OR CCC WAREHOUSE CODE NO.
U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
SIGNATURE AUTHORITY
(2) ____________________________________________________________________ (full legal nam e of firm) (or sole proprietor)
at (3A) ______________________________________ State of (3B) _______________________________authorizes
(4) (Enter the name(s) and title(s) of person(s), other than corporate officers, partners, members, or proprietors, w ho are authorized to sign):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
to sign any and all applications for approval, warehouse operator’s bonds, storage agreements or contracts, and such
other documents required by Commodity Credit Corporation (CCC) which pertain to the handling and storage by
the firm of commodities owned by or pledged to CCC.
The signing of such documents by the above-named person(s) prior to adoption of this Signature Authority is
hereby ratified and approved.
I hereby certify that this Signature Authority is authorized pursuant to the organizational document listed below in
block 6.
5. FULL LEGAL NAME OF FIRM OR SOLE PROPRIETOR
6. BY AUTHORITY OF (Except with respect to Sole Proprietorship):
a.
b.
Articles of Incorporation
Articles of Organization
c.
d.
Articles of Agreement
Other (Explain):
7. BY
8. TITLE
9. DATE
PRIVACY ACT AND PUBLIC BURDEN STATEMENTS
The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. The
authority for requesting the following information is 15 U.S.C. 714b. The information will be used to determine if the person signing contractual documents has
the authority to represent the company. Furnishing the requested information is required if the officers of a corporation or cooperative will not be signing the
contract documents. Failure to furnish the requested information will result in CCC not accepting any contract document that is signed by someone not
designated with the authority of the Board of Directors. This information may be provided to other agencies, Internal Revenue Service, Department of Justice,
or other State and Federal law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud
statutes, including 18 U.S.C. 286, 287, 371, 641, 651, 1001; 15 U.S.C. 714m; and 31 U.S.C. 3729, may be applicable to the information provided.
The authority for collecting the following information is Public Law 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 2 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. RETURN THIS COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE, P.O. BOX 419205, STOP 8748, KANSAS
CITY, MO 64141-6205.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion,
age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who
require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720­
2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW,
Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.