This form is available electronically.

 U.S. DEPARTMENT OF AGRICULTURE

 Agricultural Marketing Service

WA-51 

(04-19-19)

FINANCIAL STATEMENT

RETURN TO:

WAREHOUSE AND COMMODITY 

MANAGEMENT DIVISION

FINANCIAL REVIEW 

PO Box 419205, STOP 9148

KANSAS CITY, MO 64141-6205

FAX: 844-930-0174

warehousing@usda.gov

FOR OVERNIGHT DELIVERY:

WAREHOUSE AND COMMODITY 

MANAGEMENT DIVISION

FINANCIAL REVIEW

2312 EAST BANNISTER RD

STOP 9148

KANSAS CITY, MO 64131-3011

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

CFR Part 1427, and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used by the Financial Review Branch in the review of completing the terms of 

an agreement between the warehouse operator and CCC. 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-3, Consultants File. Providing the requested information is voluntary. However, failure to furnish the requested information will result 

in a determination of ineligibility to enter into a new agreement or retain an existing agreement with CCC. 

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 45 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. 

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.

1A. NAME (Corporation, Limited Liability Company, Partnership, or Individual’s 

Name)

2A. ADDRESS (Include Street, City, State, Zip Code)

1B. Telephone Number (Area Code) 1C. FAX Number (Area Code) 2B. E-mail (If available)

3. STATEMENT PREPARED BY:

Independent CPA

Independent Public Accountant

Other (Explain in Item 26)

4. FORM OF BUSINESS:

Corporation (Co-op)

Corporation (Reg)

Corporation (Subchapter S)

Limited Liability Company

Partnership

Individual Proprietorship

5. RESERVED 6. FISCAL CLOSING DATE (MM-DD-YYYY) 7. DATE OF ENTITY FORMATION (MM-DD-YYYY)

8. ORGANIZATIONAL INFORMATION

(To be completed by Corporation, Limited Liability Company, Partnership, and Individual Proprietorship.) SHARES OF 

STOCK HELD

A. NAME OF PRESIDENT, MEMBER, PARTNER, OR INDIVIDUAL HOME ADDRESS AND PHONE NUMBER (Include Area Code)

B. NAME OF VICE PRESIDENT, MEMBER, OR PARTNER HOME ADDRESS AND PHONE NUMBER (Include Area Code)

C. NAME OF SECRETARY, MEMBER, OR PARTNER HOME ADDRESS AND PHONE NUMBER (Include Area Code)

D. NAME OF TREASURER, MEMBER, OR PARTNER HOME ADDRESS AND PHONE NUMBER (Include Area Code)

E. NAME OF GENERAL MANAGER, MEMBER, OR OFFICER HOME ADDRESS AND PHONE NUMBER (Include Area Code)

9. DIRECTORS OF CORPORATION (Attach additional sheet if more space is needed)

A. NAME B. OCCUPATION C. HOME ADDRESS D. SHARES OF

STOCK HELD

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.
 

 

WA-51 (04-19-19) Page 2 or 4

10. STATEMENT OF ASSETS AND LIABILITES: Reflected by company books as of (Month, Day, Year)

11. CURRENT ASSETS

A. Cash on hand and in banks $

B. Accounts Receivable $

C. Other: $

D. Notes Receivable-Secured Trade $

E. Other: $

F. Notes Receivable-Unsecured Trade $

G. Other: $

H. Less: Reserve for bad debts $( ) I.

$

J. Merchandise Inventory (How valued? (1) ) (2)

$

K. Other current assets, including Government securities (Enumerate):

(1) $

(2) $ (3)

$

11L. TOTAL CURRENT ASSETS (add Items 11A, 11I, and 11K(3)) $

12. FIXED ASSETS

A. FIXED ASSETS Land (Describe under Schedule A) $

FIXED ASSETS B. COST C. DEPRECIATION D. BOOK VALUE

Buildings $ $ $

Machinery and Equipment $ $ $

Furniture and Fixtures $ $ $

Leasehold Improvements $ $ $

Appreciation of Fixed Assets $ $ $

12E. TOTAL FIXED ASSETS (add Items 12A and all entries from column 12D) $

13. OTHER INVESTMENT AND ASSETS

13. OTHER INVESTMENTS AND ASSETS (Specify):

A. $

B. $

C. $ 

D. $ 

13E. TOTAL INVESTMENTS AND ASSETS $ 

14. TOTAL ASSETS (ITEMS 11L, 12E, 13E) $ 

SCHEDULE A 15. DESCRIPTION OF REAL ESTATE

A. LAND DESCRIPTION B. LOCATION C. IMPROVEMENTS
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WA-51 (04-19-19) Page 3 of 4

16. CURRENT LIABILITES

A. Accounts payable $ 

B. Notes payable (due within 1 year):

 (1) Secured $ 

 (2) Unsecured $ (3)

$ 

C. Real estate encumbrances (due within 1 year) $ 

D. Accrued interest $ 

E. Accrued taxes $

F. Other accrued expenses (taxes, wages, etc.): $ 

G. Other current liabilities (Enumerate):

 (1) $ 

(2) $ 

 (3) $ 

 (4) $ (5)

$ 

16H. TOTAL CURRENT LIABILITIES (add Items 16A through 16G(5)) $ 

17. LONG-TERM LIABILITES (Due after 1 year)

A. Notes payable $ 

B. Real estate encumbrances (Describe under Schedule B) (1)

$ 

(2)

$ 

18. OTHER LIABILITES (Specify): 

A. $ 

B. $ 

C. $ 

D. $ 

E. $ 

F. $ G.

$ 

19. NET WORTH

CAPITAL

NO. SHARES

AUTHORIZED

PAR VALUE

PER SHARE

NO. SHARES

ISSUED

A. Common stock $ 

B. Preferred stock $ 

OTHER

C. Retained Earnings $ 

D. (Specify: paid in capital, appraisal, members' equity, partnership equity, individual equity, etc).

(1)

(2)

(3)

(4) (5)

$ 

19E. TOTAL NET WORTH (Reconcile under Schedule C) (add Items 19A, 19B, 19C, and 19D(5)) $ 

19F. TOTAL LIABILITIES AND NET WORTH (add Items 16H, 17B(2), 18G, and 19E) $ 

SCHEDULE B 20. ANALYSIS OF REAL ESTATE ENCUMBRANCES

A. NATURE OF ENCUMBRANCE B. INTEREST RATE C. PAYMENT SCHEDULE D. MATURITY DATE E. BALANCE DUE
WA-51 (04-19-19) Page 4 of 4

SCHEDULE C 21. RECONCILIATION OF NET WORTH

NET WORTH (From prior financial statements or Form WA-51)

A. Capital outstanding (For corporations) $ 

B. Retained Earnings (For corporations) $ 

C. Capital Account (For partnerships and others) $ 

D. Additions during this accounting period:

(1) Stock issued $ 

(2) Net profit $ 

(3) Other (Explain): $ (4)

$ 

E. Deductions during this accounting period:

(1) Stock retired $ 

(2) Net loss $ 

(3) Other (Explain): $ (4)

$ 

 21F. TOTAL NET WORTH (This Form WA-51) (add Items 21A through 21D(4), less Item $ 

22 - 27. GENERAL INFORMATION

22A. WHICH, IF ANY, OF THE ASSETS LISTED ON PAGE 2 ARE EXEMPT FROM 

 EXECUTION AND LEVY?

22B. ON WHAT GROUNDS IS EXEMPTION CLAIMED?

23. BANK(S) WITH WHICH BANKING BUSINESS IS DONE:

A. NAME OF BANK B. LOCATION OF BANK C. AMOUNT OF LINE OF CREDIT

24. WHAT FIRE LOSS, IF ANY, HAVE YOU SUFFERED SINCE THE DATE OF YOUR PREVIOUS STATEMENT (Give particulars)

25.

AMOUNT OF PROPERTY

INSURANCE COVERAGE 

(Give dollar values)

AMOUNTS SHOWN HERE MUST APPLY ONLY TO CORRESPONDING ASSETS SHOWN 

ON THE BALANCE SHEET

25A. BUILDINGS 25B. FIXTURES AND 

EQUIPMENT

25C. MERCHANDISE 

 INVENTORY (If any)

25D. STORAGE 

OBLIGATIONS (If any)

26. DESCRIBE CONTINGENT LIABILITIES, IF ANY NOT SHOWN ON PAGE 3.

27. REMARKS (Use this area or a separate sheet to furnish additional information needed to clarify any of the above statements.)

28. CERTIFICATION

Under penalty of perjury, I declare that I have examined the above financial statement, including any attachments, and that to the best of my 

knowledge and belief it is a true, correct, and complete statement of the financial condition of the above-named warehouse operator as of 

the date shown on page 2 or attached balance sheet.

28A. NAME (Corporation, Limited Liability Company, Partnership, or Individual) 28B SIGNATURE (BY)

28C. TITLE/Relationship of the Individual Signing in a Representative Capacity 28D. DATE SIGNED (MM-DD-YYYY)