This form is available electronically Form Approved – OMB No. 0581-0305 

WA-51-2 U.S. DEPARTMENT OF AGRICULTURE 

(07-31-18) Agricultural Marketing Service 

FINANCIAL STATEMENT SUPPLEMENT 

(For Agricultural Products) 

RETURN TO: FOR OVERNIGHT DELIVERY 

USDA-AMS-WCMD-LSCB 

Financial Review 

P.O. Box 419205 

Stop 8758 

Kansas City, MO 64141-6205 

FAX No. 877- 217-1945 

USDA-AMS-WCMD-LSCB 

Attention: Financial Review 

2312 East Bannister Rd. 

STOP 8758 

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 735, 

7 CFR Part 1423, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used 

to file information for review in meeting financial reporting requirements under the United States Warehouse Act. 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 obtain new licensing or retain existing licensing under the United States Warehouse 

Act. 

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB 

control number. The valid OMB control number for this information collection is 0581-0305. The time required to complete this information collection is estimated to average 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 THE WAREHOUSE 

AND COMMODITY MANAGEMENT DIVISION AT THE APPROPRIATE ADDRESS AT THE TOP OF THIS FORM. 

1A. Name (Corporation, Limited Liability Company, Partnership, or 

Individual’s Name)

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

(If applicable) 

1B. Telephone Number (Area Code) 1C. FAX Number (Area Code) 2B. E-Mail Address 

3. Statement Prepared By: 

Independent CPA 

Independent Public Accountant 

Other (Explain in Item 15) 

4. Form of Business: 

Corporation (Co-op) Limited Liability Company 

Corporation (Reg) Partnership 

Corporation (Subchapter S) 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 (Zip Code) and Telephone Number (Area Code) 

B. Name of Vice President, Member, or Partner Home Address (Zip Code) and Telephone Number (Area Code) 

C. Name of Secretary, Member, or Partner Home Address (Zip Code) and Telephone Number (Area Code) 

D. Name of Treasurer, Member, or Partner Home Address (Zip Code) and Telephone Number (Area Code) 

E. Name of General Manager, Member, or Like Officer Home Address (Zip Code) and Telephone Number (Area Code) 

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

A. 

Name 

B. 

Occupation 

C. 

Home Address 

D. 

Shares of 

Stock Held 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WA-51-2 (07-31-18) Page 2 

10. All banks where Warehouse Operator obtains banking services: 

A. 

Name of Bank 

B. 

Location of Bank 

C. 

Telephone Number 

(Including Area Code) 

11. Do you have a line of credit? 

NO YES (If “YES”, list name and address of lending agency) 

A. 

Name of Lending Institution 

B. 

Address of Lending Institution 

C. 

Amount of Line Credit 

$ 

$ 

12. Who is the beneficiary of the cash value life insurance policy? 

13. Insurance Amount of 

Fire Insurance 

coverage 

(Give dollar values) 

Amounts shown here must apply to corresponding assets shown on the balance sheet 

A. 

Buildings 

B. 

Fixtures and Equipment 

C. 

Total 

D. 

Vehicles – Rolling Stock 

$ $ $ $ 

14. Inventory – Limit of Liability Provisional Stock Specific $ 

15. Remarks: (Use this space to furnish additional information needed to clarify any of the above statements. If more space is needed, attach additional sheets.) 

16. CERTIFICATION 

Under penalty of perjury, I declare that I have examined the enclosed financial statement, including any attachments, and it is a true, correct, and 

complete statement of the financial conditions of the above-named Warehouse Operator as of the date shown on the attached balance sheet and 

that the information contained in the Financial Statement Supplement is true and correct. 

A. Name of Warehouse Operator (Legal Entity) B. Warehouse Operator’s Signature 

C. Title (Officer, Member, Partner, Proprietor) D. Date Signed (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. 
 

 

 

 

Instructions For WA 51-2 

FINANCIAL STATEMENT SUPPLEMENT 

Warehouse operators use this form to file information for review by the Financial Review Branch in 

meeting the financial reporting requirements for the United States Warehouse Act and the Commodity 

Credit Corporation Storage Agreements. 

Submit the original of the completed form in hard copy or facsimile to the License and Storage Contract 

Branch (LSCB), ATTN: Financial Review STOP 8758, P.O. Box 419205, Kansas City, MO 64141-6205; 

or FAX 877-217-1945. Customers who have established electronic access credentials with LSCB may 

electronically transmit this form to LSCB. Features for transmitting the form electronically are available 

to those customers with access credentials only. If you would like to establish online access credentials 

with USDA, follow the instructions provided at the USDA eForms web site. 

Warehouse Operator applicants and annual reporters must complete Items 1 

through 16. 

Fld Name/ 

Item No. 

Instruction 

1 

Name 

1A. Enter the warehouse operator’s full legal name. See Examples 

below: 

Example 1: For a proprietor, enter, for example, “Susan Doe”.

Example 2: For a corporation, enter, for example, “Doe, Inc.”

Example 3. For a general partnership, enter, for example “Letitia 

Doe, Frank Doe, Selma Doe, and James Doe, co-partners, trading 

as Doe Farms”

Example 4. For a limited partnership, enter, for example “Doe

Farms Limited Partnership, Selma Doe, General Partner” 

1B. Enter warehouse operator’s telephone number as 

XXX-XXX- XXXX. 

1C. Enter warehouse operator’s fax number as 

XXX-XXX-XXXX. 
 

Fld Name/ 

Item No. 

Instruction 

2 

Address 

Enter the applicant’s complete mailing address and email (if 

applicable). 

3 

Statement 

Prepared by 

Check the box that describes the person who prepared the 

accompanying financial statement. 

4 

Form of 

Business 

Check the box that describes the nature of the organization of the 

applicant or reporting entity. 

5 

Reserved 

Leave blank. 

6 

Fiscal Closing 

Date 

Enter the date of the fiscal year close (month, day, year). 

7 Enter the date of entity formation. In the case of a corporation that 

Date of Entity is the date of incorporation. In the case of a partnership, enter the 

Formation date the agreement was signed. In the case of an LLC, enter the 

date documents were filed with the secretary of state. Do not 

complete if a proprietor. 

8 A - E 

Organizational 

Information 

8 A-E. For a corporation: 

Enter the name of each officer and the general manager where 

indicated, their home address, their home phone number, and the 

total number of shares of stock owned. 

For a limited liability company: 

Enter the name of each member, their home address (if an 

individual) or office address (if a corporation or entity other than 

individual). 

For a partnership: 

Enter the name of each of the partners, their home address (if an 

individual) or office address (if a corporation or entity other than 

individual). 

For a proprietor: 

Enter the name, home address and phone number of the individual. 

9 A-D 9A. Enter the name of each of the directors of a corporation. 

Directors of 

Corporation 9B. Enter the occupation of each of the directors of a corporation. 

9C. Enter the home address of each of the directors of a 

corporation. 

9D. Enter the number of shares of stock held for each of the 

directors of the corporation. 
 

 

Fld Name/ 

Item No. 

Instruction 

10 A-C 

All Banks (etc.) 

Enter the name of each bank used by the applicant or reporting 

entity, its mailing address, and telephone number where indicated. 

10A. Enter the name of the bank. 

10B. Enter the complete location address of the bank. 

10C Enter the complete phone number of the bank including the 

area code. 

11 A-C 

Do you have a 

line of credit? 

Enter "X" or checkmark in the appropriate box the fact of a line of 

credit. 

11A. If “YES” enter the name of the lending institution with whom 

the applicant or reporting entity has a line of credit. 

11B. Enter the complete mailing address of the lending institution 

in Item 11A. 

11C. Enter the amount of the line of credit of the lending 

institution in Item 11A. 

12 

Who is (etc.) Enter the name of the beneficiary of any cash value life insurance. 

13 A - D 

Insurance 13A. Enter the dollar value of limits of insurance covering the 

buildings that are on the accompanying balance sheet. 

13B. Enter the dollar value of limits of insurance covering the 

fixtures and equipment that are on the accompanying balance sheet. 

13C. Enter the dollar values of limits of insurance covering the 

total fixed assets that are on the accompanying balance sheet. 

13D. Enter the dollar values of limits of insurance covering the 

vehicles or rolling stock that are on the accompanying balance 

sheet. 

14 

Inventory 

Enter the limit of liability of insurance on inventory and check the 

box the nature of that insurance, whether provisional stock 

reporting policy or specific limit insurance policy. 

15 

Remarks 

Enter any information needed to interpret or clarify the financial 

information presented. 

16 

Certification 

16A.Warehouse Operator – Enter the name of the applicant 

16B Enter the signature of the applicant. 

16C. Title – Enter the business title of the individual applicant or 

reporting entity. 

16D. Enter the date of signature (mm, dd, yy) 

BE SURE TO INCLUDE A FINANCIAL STATEMENT.