KC-1622 U. S. DEPARTMENT OF AGRICULTURE

(04-19-19) Agricultural Marketing Service

SIGNATURE AUTHORITY

1. STORAGE AGREEMENT AND/OR CCC WAREHOUSE CODE NO.

(2) (full legal name of firm) (or soleproprietor)

at (3A) State of (3B) authorizes

(4) (Enter the name(s) and title(s) of person(s), other than corporate officers, partners, members, or proprietors, who are authorized to sign):

to sign any and all applications for approval, warehouse operator’s bonds, storage agreements or contracts, and such 

other documents required by Commodity Credit Corporation (CCC) which pertain to the handling and storage by 

the firm of commodities owned by or pledged to CCC.

The signing of such documents by the above-named person(s) prior to adoption of this Signature Authority is 

hereby ratified and approved. 

I hereby certify that this Signature Authority is authorized pursuant to the organizational document listed below in 

block 6.

5. FULL LEGAL NAME OF FIRM OR SOLE PROPRIETOR

6. BY AUTHORITY OF (Except with respect to Sole Proprietorship):

a. Articles of Incorporation c. Articles of Agreement

b. Articles of Organization d. Other (Explain):

7. BY

8. TITLE 9. DATE

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting 

the following information is 15 U.S.C. 714b. The information will be used to determine if the person signing contractual documents has the authority to represent the company. Furnishing 

the requested information is required if the officers of a corporation or cooperative will not be signing the contract documents. Failure to furnish the requested information will result in 

CCC not accepting any contract document that is signed by someone not designated with the authority of the Board of Directors. This information may be provided to other agencies, 

Internal Revenue Service, 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 U.S.C. 286, 287, 371, 641, 651, 1001; 15 U.S.C. 714m; and 31 U.S.C. 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 2 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. 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.

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 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.