Form W-1 Application for Iowa Warehouse Operator License - Iowa

Form W-1 or the "Application For Iowa Warehouse Operator License" is a form issued by the Iowa Department of Agriculture and Land Stewardship.

Download a PDF version of the Form W-1 down below or find it on the Iowa Department of Agriculture and Land Stewardship Forms website.

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W-1
BEFORE THE IOWA DEPARTMENT OF AGRICULTURE AND LAND STEWARDSHIP
APPLICATION FOR IOWA WAREHOUSE OPERATOR LICENSE
LICENSE NO.: W-
The undersigned hereby makes application to participate in the Iowa Grain Depositors and Sellers Indemnity Fund in conformity with the
provisions of Iowa Code Chapter 203D and to obtain a Warehouse Operator License in conformity with the provisions of Iowa Code Chapter
203C and the Rules of the Department of Agriculture and Land Stewardship, and in support thereof, submits the following information:
Full and correct name of applicant
Corporate Office
Mail Address
City
State
Zip Code
Location of Business
Street Address
City
County
State
Zip Code
Mailing Address
Street No. or P.O. Box
City
State
Zip Code
Name of Manager
Business Phone
Fax No.
Applicant is a/an
doing business under the name of
(Corporation, Individual, Partnership or Limited Liability Company)
Fiscal Year End of applicant is
The applicant, if a corporation or a limited liability company, was organized under the laws of the state o
and is
authorized to do business in the State of Iowa , and that the names and addresses of the officers are as follows:
President
Address
Secretary
Address
Treasurer
Address
If applicant is a partnership, the partners are as follows:
Name
Address
Name
Address
Name
Address
The warehouse facility or facilities proposed to be licensed is or are as follows: (If additional space is needed, attach sheet)
STATION
COUNTY
TYPE OF CONSTRUCTION, NUMBER AND
NUMBER
PRODUCTS TO
CAPACITY
TOWN
SECTION OF EACH STRUCTURE TO BE LICENSED
OF BINS
BE STORED
For Office Use Only
CAP
Approved:
N/W
EFFECTIVE
Signature of Warehouse Examiner
FEES
CHECK #
(CONTINUED ON REVERSE)
(3/14)
W-1
BEFORE THE IOWA DEPARTMENT OF AGRICULTURE AND LAND STEWARDSHIP
APPLICATION FOR IOWA WAREHOUSE OPERATOR LICENSE
LICENSE NO.: W-
The undersigned hereby makes application to participate in the Iowa Grain Depositors and Sellers Indemnity Fund in conformity with the
provisions of Iowa Code Chapter 203D and to obtain a Warehouse Operator License in conformity with the provisions of Iowa Code Chapter
203C and the Rules of the Department of Agriculture and Land Stewardship, and in support thereof, submits the following information:
Full and correct name of applicant
Corporate Office
Mail Address
City
State
Zip Code
Location of Business
Street Address
City
County
State
Zip Code
Mailing Address
Street No. or P.O. Box
City
State
Zip Code
Name of Manager
Business Phone
Fax No.
Applicant is a/an
doing business under the name of
(Corporation, Individual, Partnership or Limited Liability Company)
Fiscal Year End of applicant is
The applicant, if a corporation or a limited liability company, was organized under the laws of the state o
and is
authorized to do business in the State of Iowa , and that the names and addresses of the officers are as follows:
President
Address
Secretary
Address
Treasurer
Address
If applicant is a partnership, the partners are as follows:
Name
Address
Name
Address
Name
Address
The warehouse facility or facilities proposed to be licensed is or are as follows: (If additional space is needed, attach sheet)
STATION
COUNTY
TYPE OF CONSTRUCTION, NUMBER AND
NUMBER
PRODUCTS TO
CAPACITY
TOWN
SECTION OF EACH STRUCTURE TO BE LICENSED
OF BINS
BE STORED
For Office Use Only
CAP
Approved:
N/W
EFFECTIVE
Signature of Warehouse Examiner
FEES
CHECK #
(CONTINUED ON REVERSE)
(3/14)
D
D
D
D
_ _ _
}
D
D
D
FEES:
A. In Box A, list the total of all storage capacities listed on page 1
A)
Bushels
B) $
B. Multiply the amount in Box A by $0.00014. Enter this amount in Box B
C. In Box C, enter the lesser of Box B or $500.00
C) $
D. In Box D, enter the greater of Box C or $50.00
D) $
The amount in Box D is your grain indemnity fund participation fee.
E. For the capacity in Box A, find the correct license fee in chart E below:
Chart E
BUSHELS OF STORAGE CAPACITY
FEE
BUSHELS OF STORAGE CAPACITY
FEE
100,000 or less
$58
3,000,001 TO 4,750,000
$307
100,001 TO 750,000
$125
4,750,001 TO 9,500,000
$374
750,001 TO 1,500,000
$191
9,500,001 or more
$440
1,500,001 TO 3,000,000
$249
Divide the amount determined in Chart E by 12 and multiply by the number of months from the current month to
E) $
three months past your company's fiscal year end. Enter this in Box E. This is your prorated license fee.
F. Enter the total of the amounts in Box D and E. This is the total amount due. PAY THIS AMOUNT
F) $
To obtain help in determining your storage capacity or fees due, please call IDALS at 515-281-5987
Applicant will submit such further evidence in support of statements made in the application as required by the Department. As a condition to the granting
of this application, applicant agrees to comply with and abide by all terms of Iowa Code Chapter 203C and 203D, and such rules as are or may be prescribed
thereunder by the Department. Applicant acknowledges that the storage facilities listed in this application are whether owned by or have been leased to the
applicant and that applicant has access to and control over these facilities.
Dated this
day of
,
By
Signature and Title
OATH
State of
ss.
County of
I,
being first duly sworn on oath, depose and say that I am the
Title
of
, that I have read the foregoing application, know its purpose, am
Business Name
familiar with the facts therein set forth and the same is true and correct.
Signature
Subscribed and sworn to before me, a Notary Public in and for the State and County above named, this
day of
,
.
Notary Public
Application must be signed and sworn to by applicant, if an individual; by a member of the partnership, if applicant is a partnership; or by any
officer of the corporation, if the applicant is incorporated.
(3/14)

Download Form W-1 Application for Iowa Warehouse Operator License - Iowa

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