Free 18789.PDF - Indiana

WAREHOUSE LICENSE ANNUAL RENEWAL
State Form 18789 (R3 / 2-98 ) Approved by State Board of Accounts 1997

OFFICE USE ONLY Transaction # Check # Initials

v Recycled Paper

Indiana Grain Buyers and Warehouse Licensing Agency ISTA Center, Suite 416 150 West Market Street Indianapolis, Indiana 46204-2810 (317)232-1356

Section A: Location #: Name of business: Address: Individual in charge: Phone #:

COMPANY INFORMATION FAX #: d/b/a: County: Title: City: State: ZIP code:

Section B: Please check "T" only one: Proprietor Partnership

FORM OF BUSINESS

Section C: From:

FOR RENEWAL PERIOD To:

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9 Corporation 9Other, specify:
LICENSING FEES

Section D: 1). License Fee: (Includes 1 facility) 2). Number of facilities: (less 1 included above) 3). TOTAL FEE (Line 1 plus Line 2) due on or before:

(1) Multiplied by $50.00: (2) (3)

Make check payable to: Indiana Grain Buyers and Warehouse Licensing Agency Section E: 1). MINIMUM Net Worth required: 2). Total bushel storage capacity: 3). REQUIRED NET WORTH: Total of Line 1 plus Line 2. 4). Company's current Net Worth (as of: ) from reviewed financial statement: X Ten Cents (10¢) = COMPUTATION OF NET WORTH $15,000.00 (1) (2) (3) (4) (5)

5). If the required Net Worth is greater than the actual Net Worth above, enter deficiency in required Net Worth: Section : F 1). Minimum Amount of Bond Required. 2). Total bushel storage capacity of all facilities: 3). Enter the larger amount of Lines 1 or 2: 4). BOND REQUIRED: Enter the smaller of Line 3 or $100,000.00. 5). If the $15,000.00 minimum Net Worth requirement is met, Net Worth deficiencies can be added to the bond requirement. Enter deficiency in Net Worth from Line 5, Section E above: 6). TOTAL BOND REQUIRED: Add Lines 4 and 5. Carrier of bond, if known: Form of bond: X Ten Cents (10¢) = COMPUTATION OF BOND $10,000.00

(1) (2) (3) (4) (5) (6)

9 Surety Cash Deposit 9

Letter of Credit

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FORMAL APPLICATION AND CERTIFICATION I hereby make application for renewal of a license for the company identified above, under the provisions of the Indiana Grain Buyers and Warehouse Licensing and Bonding Law, IC 26-3-7, as amended. I understand and agree, as a condition to the issuance of a license renewal, to make my business premises, records and inventories available for inspection by the Indiana Grain Buyers and Warehouse Licensing Agency, and to cooperate and assist in such inspections. I affirm, under the penalties provided for in the law, that the information in this application is true and accurate to the best of my knowledge and belief. Typed or printed name of applicant: Signature of applicant: Date: