This form is available electronically.

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

(04-19-19) Commodity Credit Corporation

SUPPLEMENT TO FORM CCC-28-1, 

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 or 

when requesting a change in a warehouse section. 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 or when requesting a change in a warehouse section.

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. Complete a separate CCC-28-1A for each section of the facility.

5. Legal Name of Entity (Enter same name as in Item 5 of CCC-28-1)

6A. This Report Applies To 

 Warehouse Code Number:

6B. Section 6C. Location (Give street address, town, county, and state. If not in town,

 give road, direction, and approximate distance from named town.)

7A. Warehouse is: 7B. Lessor Name and Address (Include Zip Code) 7C. Expiration date of lease

 (MM-DD-YYYY)

 Owned Leased

7D. Option to renew? YES NO 7E. Will you guarantee a 120-day notice if lease is cancelled? YES NO

8. Area (square feet) for storage:

A. Dry : B. Cooler: C. Tank Storage in Cwt. for In-Process Sugar:

9. Does warehouse operator have complete control of warehouse space? 10. Is warehouse ready to operate?

 YES NO YES NO

11. Type of construction: 12A. Does warehouse have direct access to rail siding?

 Concrete

 Brick

 Iron clad

 Wood frame YES NO, truck only

12B. Enter name of railroad(s) and initial(s) on which rail shipments are

 received and loaded out if direct access. (Such as Burlington 

 Northern Santa Fe, BNSF).

12C. If no direct access is available but rail shipment is offered, enter the 

 location and name of railroad(s) and initial(s) where rail shipments are 

 received and loaded out. (Such as Jeanerette, LA; Burlington Northern 

 Santa Fe, BNSF).

13. Comments

14. 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.

14A. Legal Name of Entity (Same as Item 5)

14B. By 14C. Title 14D. 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, AD3027, 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.