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Grain Customer Profile

In order to serve you better, through quicker and more accurate settlements, please take a moment to complete the following Customer Profile. If you have more than one entity or farm number (FSA#), please complete a form for each. If this FSA# has splits, fill in the corresponding names and percentages so we can get your splits into our new system correctly. Addresses and contact information for each landlord and farm is very important and aids us in getting your settlements correct the first time. As always, feel free to contact us via email, phone, or come in and see us in person.

Lien Information: Whenever the statewide lien search lists a lien holder, we are required to add that lien to the settlement. Please check to be sure your lien information is correct.

Thank you!




Name:   FSA#:  
Address:  
Home Phone:   Shop Phone:   Cell Phone:  
Email:  
For Crop Year:  
Grain is to be received as (Farm Name): 
If this FSA# has splits, please list by name and percentage below:
Name:   Percentage:  
Name:   Percentage:  
Name:   Percentage:  
Name:   Percentage:  
Name:   Percentage:  
Commodity:   Variety:   Acres:   Preferred Elevator:  
Commodity:   Variety:   Acres:   Preferred Elevator:  
Commodity:   Variety:   Acres:   Preferred Elevator:  
Commodity:   Variety:   Acres:   Preferred Elevator:  
Commodity:   Variety:   Acres:   Preferred Elevator:  
Who is authorized to sell this grain?   If each person/entity listed is responsible for their own sales, enter "each sells their own".
Truck Freight: The grain received from this entity is hauled to the elevator by:
Grower:   Hired Truck:  
Special Instructions:  
Date  
Please type the text in the box.


   
  

Important: We realize circumstances change and this information may need to be updated. Please contact the Grain Department as necessary.
 
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