This form is available electronically.

CCC-28-1 U.S. DEPARTMENT OF AGRICULTURE 

(04-19-19) Commodity Credit Corporation

APPLICATION FOR APPROVAL OF WAREHOUSE 

Sugar Storage Agreement (SSA)

LEAVE BLANK - CCC USE ONLY

1. Approved Date (MM-DD-YYYY) 2. Agreement Number

3. Warehouse Code Number 4. Master Code Number

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 1423, 7 

CFR Part 1435, and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used to apply for a Sugar Storage Agreement to store CCC owned and loan 

sugar. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access

to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and 

USDA/FSA-14, Applicant/Borrower. Providing the requested information is voluntary. However, failure to furnish the requested information will result in the inability to apply for a Sugar Storage 

Agreement to store CCC owned and loan sugar.

The authority for collecting the following information is Pub. L. 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 1 hour 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.

The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO: 

warehousing@usda.gov or THE WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, Beacon Facility, PO BOX 419205 STOP 9148, KANSAS CITY, MO 64141-6205.

The undersigned hereby applies for a Sugar Storage Agreement in order to be eligible to store sugar on behalf of CCC or requests amendment to 

the current application on file.

5. Legal Name of Entity 6. Warehouse Location(s) (Town, County, State)

7A. Name of Warehouse Manager or Superintendent 7B. Telephone Number (Include Area Code) 7C. Fax Number (Include Area Code)

8A. Type of Warehouse License: 8B. License Number 9. Type of Operating Entity:

 Not licensed

 State

 U.S. Warehouse Act

Corporation/Cooperative

 General Partnership

 Limited Partnership/LLC

 Individual/ Proprietorship

 Other 

 (Specify):

10A. Contact Mailing Address (Include Zip Code) 10B. Contact Person for CCC :

10C. Telephone Number (Include Area Code):

10D. Fax Number (Include Area Code):

10E. E-mail:

11. Mailing Address for Loading Orders and Periodic Invoices 12A. Payee Disbursement Mailing Address (Include Zip Code)

12B. Telephone Number (Include Area Code):

12C. Fax Number (Include Area Code):

13. Name, Title, and Address of (Include Zip Code):

• Officers, if a Corporation or Cooperative

• Partners, if a Partnership

• Individual, if a Proprietorship

• All members of LLC, if a LLC

13A.

NAME

13B.

TITLE

13C.

ADDRESS
CCC-28-1 (04-19-19) PAGE 2 OF 2

14. Total Handling Capacity Combining all Locations Per Normal Workday (Report Weight in Hundredweight (Cwt.)):

A. 

TYPE OF CONVEYANCE

B. 

UNLOAD (cwt)

C.

LOAD OUT (cwt)

Railroad Car

Truck

Barge

Vessel

15. Indicate Maximum Number of Rail Cars You are Willing to Handle in a 24-hour Workday on a Multiple-Car Basis for CCC by Location:

A.

LOCATION

B. 

RECEIVE

C. 

LOAD OUT

A.

LOCATION

B. 

RECEIVE

C. 

LOAD OUT

16. CERTIFICATION

The applicant certifies that all statements made herein are true and correct and that the applicant will operate in accordance with the 

terms and provisions of the SSA. Form must be signed by an authorized individual, i.e., corporate officer, partner or proprietor. 

Manager cannot sign unless authorized by a resolution of the Board of Directors or Power of Attorney furnished by a partner or 

proprietor.

16A. Legal Name of Entity 

16B. By 16C. Title 16D. Date (MM-DD-YYYY)

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or 

administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, 

family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases 

apply to all programs). Remedies and complaint filing deadlines vary by program or incident. 

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or 

USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other 

than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or 

write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA 

by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: 

program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.