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2o�2a��oo <br />CCG-297 (OS-18-04) <br />Pege 2 of 2 <br />IN WITNESS WHEREOF, the uodersigned parties hereto have executed this instrument <br />this (h) l lth � o f �,� Januarv , �� 2012 (year). <br />if a corporation: <br />(kJ Nan�e of Corporate (Nlortgagee) (Owner) * <br />By <br />(!) Duly Authortzecl O�cer <br />(m) Title <br />CORPORATE <br />SEAL <br />"Mortgagee" includes holder of any type of reaf estate lien. <br />*Delete "Mortgagee" or "Owner." <br />(p) S'�A'!'E OF NEBRASKA <br />(c� C�UM'rY OF' HALL } ss• ACKNOWLEDGMENT: <br />On this (r) l lth day of (s) January in the year (t) 2� 12 , before <br />me, the undersigned, a Notary Public in and for said Sfiate, peisonally appeared (u) *'� , <br />personally trnown to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is <br />{are) su6scribed to the within instrument and acknowledged to me that heJshe executed the same ia his/herltheir capacity <br />(ies), and that 6y his/herltheir signature{s} on the instrument, the individual(s) or the person on behalf of which the ' <br />individuaKsl acted. execute the instrument <br />*�Phil Mader a/k/a Phil A. Mader and Linda Mader c <br />husband and wife and phil Mader, piesident of Mader �SEAL) �'` . <br />Farms , Inc . (v} Notary Publ�c <br />GENERAI.NOTARY-SlateofNebraska Mycornmission expires(w) .�' � � �� �� <br />JANICE K. BOEHLE (Al,YI-DD-Y}'}'Y) <br />My Comm. E�. March 27, 2013 <br />The foUawing sfalemeN is made Pn accordance with fhe Privacy Act ol iB74 (5 USC SSZa) and fhe PBperwork Redudlnn Act ot f995, as mnenEed The axD+mily lmre4ues�9 <br />li�eloROwuy�ln/pmgfion is 7 CFR Peft l43E and tbe CommadRy Ged"it Cwporal'ron CharterAd, 5 USC 714 eL seq. The lNOrmallon weU be used to detemier+e eFgOditylot <br />CCC fma�mg lorfam, storsge and dry'mg equipmeat Fumishing lhe requestsd MfmrneGon ls vduntary; howevar, �viThout d CCC finandng urrcterdre program cannot ba <br />provlded. FaBurelo lexrais)t the reqt�ested iMamefloa w� resWtln denlel of CCC finar�g ernder fhiv proQrem. ThLs fnlamatFan may be provlded to otf�er agencfes.lRS <br />Oeparhr�mel W Juaflce, orother State amd FedersJ law enlwcemaM sganraes, and in respensa to a eowt megtsNafe or adminlsUeNve lribnneL Tde provJ�ions Ncrlmine! and <br />dv�f/ar�d sfBlerlea, L�ir918 t/SC 288, 287, 3Ti, 84i, 851, t�i; i5 USC 7i4m; arrd 31 USC 3729, may be appGcaMe fo fhe infOrmatiwt pNVio7ed. <br />Accadmg fo flre Papawak Reduc�+ Ar.f N f996, an agency may nnf mnduct orspansa, end a pmma is nof required to respond lo, e cdfec�n d'mtmmelion tmfassd <br />mspleys e vmqd OM8 cartrul num6er. Rre ve�d OM8 cnnho/ numherfar thfs in/nrmafion edtectFOn a 058od204. The Bme requLed to wmpfele M(slnfirmallon ea�erlbn is <br />esfimated M ewerege ?5 «d�uResPer rasponse. indudrng N�e Wrra tor revie�ving lnsbuclfons. searchtn9 exiaiG�p data so+xce� Setherin9 end mairdafM»9 the d�e n�de� and <br />compfalNg and rsviermig the callec►!on ol Ldormahen. RETURN TlifS COhIPLETED FORM TO YOflR COUAITY FSA OFF/C6 <br />by phil ?Re.a 2T President <br />