Form AG04019 "Certification of Financial Statement" - Minnesota

What Is Form AG04019?

This is a legal form that was released by the Minnesota Department of Agriculture - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Minnesota Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AG04019 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG04019 "Certification of Financial Statement" - Minnesota

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625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us/grain
PLANT PROTECTION DIVISION I GRAIN LICENSING
651-201-6011
CERTIFICATION OF FINANCIAL STATEMENT
The financial statements submitted to the Department of Agriculture for the purpose of obtaining or maintaining a
grain buyers or grain buy and store license shall be accompanied by a certification BY THE CHIEF EXECUTIVE OFFICER,
OWNER, OR THEIR DESIGNEE AND WHERE APPLICABLE ALL MEMEBERS OF THE GOVERNING BOARD OF DIRECTORS
attesting to the accuracy of the financial statements.
M.S. Section 223.17
Please sign and return to the Department of Agriculture Plant Protection Division, Grain Licensing Unit, the
following certification:
Under penalty of perjury, I certify that the financial statements submitted to the Department of Agriculture
accurately reflect the financial condition of:
(Name of Licensee)
for the period specified in the statement.
By:
Date
(Authorized Signature)
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG 04019 11/2020
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
Page 1 of 1
625 Robert Street North, Saint Paul, MN 55155-2538
www.mda.state.mn.us/grain
PLANT PROTECTION DIVISION I GRAIN LICENSING
651-201-6011
CERTIFICATION OF FINANCIAL STATEMENT
The financial statements submitted to the Department of Agriculture for the purpose of obtaining or maintaining a
grain buyers or grain buy and store license shall be accompanied by a certification BY THE CHIEF EXECUTIVE OFFICER,
OWNER, OR THEIR DESIGNEE AND WHERE APPLICABLE ALL MEMEBERS OF THE GOVERNING BOARD OF DIRECTORS
attesting to the accuracy of the financial statements.
M.S. Section 223.17
Please sign and return to the Department of Agriculture Plant Protection Division, Grain Licensing Unit, the
following certification:
Under penalty of perjury, I certify that the financial statements submitted to the Department of Agriculture
accurately reflect the financial condition of:
(Name of Licensee)
for the period specified in the statement.
By:
Date
(Authorized Signature)
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG 04019 11/2020
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
Page 1 of 1