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OHIO DEPARTMENT OF AGRICULTURE

Division of Plant Industry - Grain & Seed Section

8995 East Main Street

Reynoldsburg, OH  43068-3399

(614) 728-6410

DIVISION:

Web FORM:

Last Revised:

FORM EXPIRES:

PLNT-GS

4203-006

07/10/2003

12/31/2003

FOR DIVISION USE ONLY

Case Number: ____________

Court:___________________

Location:_________________

INDEMNITY FUND CLAIM FORM

 

CLAIM AGAINST   CLAIMANT
Name:   Name:
Mailing Address:   Mailing Address:
City, State, Zip:   City, State, Zip:
 
Commodity (file separate claim for each commodity and each type of claim):
 

Type of Claim:

Title Transfer (includes Delayed Price and Basis Contracts) Priced not settled (includes cash sale and bad checks Bailment (grain bank and storage)

If you are not sure of the claim type you have or you are not sure what category your claim falls in, please contact ODA.

Have you requested payment?   Yes    No    If yes, what date?____________________________

Summary of Claim (Fill in the information you have available.):
TICKET NUMBER DATE NET LBS. NET BU. BASE PRICE ADJUSTMENTS NET PRICE $ AMOUNT
               
               
               
               
               
               
               
               
               
               
               
               
 
Total Net Bushels:    # Total Claim Amount:    $
If you need more space than above to complete your claim, attach additional pages.  Please include copies of your scale tickets, settlement sheets, delayed price agreements, basis contracts and any other documentation to substantiate your claim.
Do you owe for moisture discounts or other conditioning charges for the bushels on this claim?   Yes   No
Have you received a partial settlement or advance on the commodity listed above?  Yes  No   If Yes, what amount?
Does the reported company claim you owe them for any other fees on this commodity, other commodities, or for any other open accounts?                        Yes     No      If Yes, how much?   $
Is this amount disputed?   Yes     No      If Yes, how much do you owe?
 

Original scale tickets attached (or photocopies thereof)

Need the originals returned.
Forward your claim to:  OHIO DEPARTMENT OF AGRICULTURE, GRAIN WAREHOUSE SECTION, 8995 EAST MAIN STREET, REYNOLDSBURG, OH  43068-3399.
   
Signature of Claimant Social Security Number (or Federal Tax ID Number)
  SSN or Fed. ID Number MUST be listed or claim cannot be processed.