See reverse side for Privacy Act, Public Burden, and Nondiscrimination Statements. 

KC-1233-A U. S. DEPARTMENT OF AGRICULTURE 

(04-19-19) Agricultural Marketing Service 

SIGNATURE 

Corporation and Cooperative - All documents must be signed by the President, Vice-President, Secretary or Treasurer. 

Any other signatures will not be accepted unless accompanied by a resolution of the Board of Directors authorizing such 

person to execute documents with CCC in connection with CCC Storage Agreements (or a resolution for that person or 

position is on file with WCMD). 

LLC - All documents must be signed by a member of the LLC. 

Partnership or All documents must be signed by one 

Joint Venture - of the partners. 

Individual or Sole All documents must be signed by the 

Proprietorship - owner. 

See reverse side for Privacy Act, Public Burden, and Nondiscrimination Statements. 

KC-1233-A U. S. DEPARTMENT OF AGRICULTURE 

(04-19-19) Agricultural Marketing Service 

SIGNATURE 

(or Power of Attorney furnished for 

other authorized signature) 

Corporation and Cooperative - All documents must be signed by the President, Vice-President, Secretary or Treasurer. 

Any other signatures will not be accepted unless accompanied by a resolution of the Board of Directors authorizing such 

person to execute documents with CCC in connection with CCC Storage Agreements (or a resolution for that person or 

position is on file with WCMD). 

LLC -

Partnership or

Joint Venture -

Individual or Sole 

Proprietorship -

All documents must be signed by a member of the LLC. 

All documents must be signed by one 

of the partners. 

All documents must be signed by the 

owner. 

(or Power of Attorney furnished for 

other authorized signature) 

See reverse side for Privacy Act, Public Burden, and Nondiscrimination Statements. 

KC-1233-A U. S. DEPARTMENT OF AGRICULTURE 

(04-19-19) Agricultural Marketing Service 

SIGNATURE 

Corporation and Cooperative - All documents must be signed by the President, Vice-President, Secretary or Treasurer. 

Any other signatures will not be accepted unless accompanied by a resolution of the Board of Directors authorizing such 

person to execute documents with CCC in connection with CCC Storage Agreements (or a resolution for that person or 

position is on file with WCMD). 

LLC -

Partnership or

Joint Venture -

Individual or Sole 

Proprietorship -

All documents must be signed by a member of the LLC. 

All documents must be signed by one 

of the partners. 

All documents must be signed by the 

owner. 

(or Power of Attorney furnished for 

other authorized signature) 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KC-1233-A (REVERSE) 

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS 

The following statements are made in accordance with the Privacy Act of 1974 (USC 552a) and the Paperwork Reduction Act of 1995, as amended. This form provides 

instructions only concerning Uniform Grain and Rice Storage Agreement documents. Information may be provided to other agencies, IRS, Department of Justice, or other State 

and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 

287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided. 

The authority for collecting the following information is Public Law 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 5 minutes 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. 

NONDISCRIMINATION STATEMENT 

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. 

KC-1233-A (REVERSE) 

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS 

The following statements are made in accordance with the Privacy Act of 1974 (USC 552a) and the Paperwork Reduction Act of 1995, as amended. This form provides 

instructions only concerning Uniform Grain and Rice Storage Agreement documents. Information may be provided to other agencies, IRS, Department of Justice, or other State 

and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 

287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided. 

The authority for collecting the following information is Public Law 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 5 minutes 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. 

NONDISCRIMINATION STATEMENT 

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. 

KC-1233-A (REVERSE) 

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS 

The following statements are made in accordance with the Privacy Act of 1974 (USC 552a) and the Paperwork Reduction Act of 1995, as amended. This form provides 

instructions only concerning Uniform Grain and Rice Storage Agreement documents. Information may be provided to other agencies, IRS, Department of Justice, or other State 

and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 

287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided. 

The authority for collecting the following information is Public Law 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 5 minutes 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. 

NONDISCRIMINATION STATEMENT 

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.