"Grain Depositors and Sellers Indemnity Fund Grain Dealer Claim Form" - Iowa

Grain Depositors and Sellers Indemnity Fund Grain Dealer Claim Form is a legal document that was released by the Iowa Department of Agriculture and Land Stewardship - a government authority operating within Iowa.

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FOR OFFICE USE ONLY
Claim No. GD-
GRAIN DEPOSITORS AND SELLERS INDEMNITY FUND
GRAIN DEALER CLAIM FORM
Name and Address of grain dealer under which claim arose:
1. Seller's Name:
By:
(FIRST \ MIDDLE \ LAST)
(NAME & TITLE)
2. Address:
Street or Box No.
City
State
Zip Code
3. Telephone No.: (
)
Area Code
4. Social Security or Fed. Tax I.D. No.
DATE
DOCUMENT
TYPE
TOTAL
REMAINING
5.
OF
NUMBER
OF
(GROSS)
(PARTIAL)
PRICE
DELIVERY
GRAIN
BUSHELS
BUSHELS
6. Prepayments/Advances:
DATE
GRAIN
SETTLEMENT
BUSHELS
AMOUNT
TYPE
SHEET NUMBER
FOR OFFICE USE ONLY
Claim No. GD-
GRAIN DEPOSITORS AND SELLERS INDEMNITY FUND
GRAIN DEALER CLAIM FORM
Name and Address of grain dealer under which claim arose:
1. Seller's Name:
By:
(FIRST \ MIDDLE \ LAST)
(NAME & TITLE)
2. Address:
Street or Box No.
City
State
Zip Code
3. Telephone No.: (
)
Area Code
4. Social Security or Fed. Tax I.D. No.
DATE
DOCUMENT
TYPE
TOTAL
REMAINING
5.
OF
NUMBER
OF
(GROSS)
(PARTIAL)
PRICE
DELIVERY
GRAIN
BUSHELS
BUSHELS
6. Prepayments/Advances:
DATE
GRAIN
SETTLEMENT
BUSHELS
AMOUNT
TYPE
SHEET NUMBER
7. Please indicate each item of documentation you are attaching to this claim:
Check returned NSF
Scale Ticket
Settlement Sheet
(Non-sufficient funds)
Other(please specify)
8. Options for payment (check one only)
Payment from Indemnity Fund first: Treat this claim as a joint claim against the Indemnity Fund and any
receivership by the Department in regard to this grain dealer, but I elect to present my claim first against
the Fund for payment of 90% of the loss up to $300,000, with the remaining 10% to be presented as a
claim in the receivership for pro rata payment, if any. I understand that in receiving payment from the
Fund, that portion of my claim in the receivership will be assigned to the Fund.
Payment from the Receivership first: Treat this claim as a joint claim against the Indemnity Fund and any
receivership by the Department in regard to this grain dealer, but I elect to present my claim first against
the receivership for pro rata distribution on the claim, with the remaining loss to be presented as a claim
against the Fund for payment of 90% of the remaining loss up to $300,000. I understand that no payment
can be made from the receivership before a minimum of 120 days and that all payments are subject to
court approval.
9. I,
(Print full name or names)
being duly sworn, state under penalty of perjury that the information stated in and attached to this
claim is true and correct to the best of my knowledge. If a partnership, I further state that I am
authorized to file this claim on behalf of the partnership.
(Signature)
(Title \ Position)
Subscribed and sworn to before me
this
day of
,
.
NOTARY PUBLIC IN AND FOR
THE STATE OF
ALL CLAIM FORMS MUST BE NOTARIZED AND RETURNED TO:
IOWA DEPARTMENT OF AGRICULTURE AND LAND STEWARDSHIP
GRAIN WAREHOUSE BUREAU
WALLACE STATE OFFICE BUILDING
DES MOINES, IOWA 50319
ALL CLAIMS MUST BE FILED WITH THE IOWA DEPARTMENT OF AGRICULTURE AND LAND STEWARDSHIP
WITHIN 120 DAYS OF CANCELLATION, TERMINATION OR REVOCATION OF THE GRAIN DEALER LICENSE
OR WITHIN 120 DAYS OF THE FILING OF A BANKRUPTCY PETITION. (Address stated above).
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