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<br />5. IN WITNESS WHEREOF, Mortgagee has executed this Agreement by signing on the (a) ��=� day
<br />of @) 1���b��e�,v� �f , (�I 201�.
<br />BY (c�
<br />TITLE (e)
<br />`3TATE OF NFHRA3KA J
<br />courrrY oF /,ia� r )
<br />Thia foregoing instrument
<br />���� , Zo�2,
<br />W� �r� �c.�
<br />• (Title'
<br />�My aommisaion expires:
<br />` .�3,..�0�
<br />d� GENERAL NOTARY- St�e of Nebraska
<br />IP�f {(qTHERiNE S. SCHULTE
<br />��"'� My Comm. Exp. May 23, 2013
<br />�
<br />was acknowledged be£ore me thie �� day of
<br />�;+� M � � , �c�
<br />(DUly Authori ed Officer)
<br />��ir m C P f� �r �e u�� cr� Amn.Y �«
<br />(Name of Mortgagee)
<br />by
<br />of
<br />��� ���
<br />� General Notary
<br />NOTE: The following statementls made in accordance with the PrivacyAct of i974 (5 U.S.C. 552a - as amendeaf). 7he authorfty foi
<br />request/ng the InformaUon ldentlBed on fhls form is the Consofldated Farm and Ru�l Development Ac� as amended (7 U.S.C.
<br />9921 g�. s�). The lnformation wld be used to determine ellg�bility and feasibility for /oans and loan guarantees, and servicfig of
<br />foans and loan guarantees. The informafion coflected on th/s form may be dfsclosed to other Federal, State, and loca/ govemmenf
<br />agencies, Trlba! agenctes, and nongovemmental entlties that have been author¢ed access to the informatlon by statute or
<br />regulatton and/or as descrfbed /n the applicable Routlne Uses fdentit7ed In the System of Records Notke for USDA/FSA-f 4,
<br />Appllcant/Borrower. Provtding the requesteal Information is volunfary. ! fallur� to fumish the requested information may
<br />resull In a denJa/ for loans and loen guarentees, and servtcing of loans and /oan guarantees. The provisions of cNm/nal and civif
<br />fiaud, privacy, and other stafutes may be applkable to the (nformaflan provldad.
<br />Accortitng to the Papenvork Reduction Act of ?995, an agency mey not conduct or sponsor, and a person is not requfred to
<br />respond to, a collecdon oflnformatfon unless it displays a vaBd OMB contro! number. The vard OM8 control num6er for thls
<br />lnformation coOecU�n Is 0560-0237. The t/me requfied to complete thls InformaBon col/ectlon !s esHmated to average 30 mtnutes
<br />per response, including the time for revlewing lnstrucUons, sea�hing exlsffng data sources, gathering and malntaining the data
<br />needeal, and compledng and revlewing the codectlon of Information. RETURN TH/S COMPLETFD FORM TO YOUR CDUNTY
<br />The U.S. Deparfinent ofAgrlculture (USDA) proidbits dfscriminatlan Jn all Its programs end activiBes on tl�e besls ot raee, color; naBonaf oiJgin, age, �sabllity, and
<br />where appRceble, sex, madtai status, /errd8af status, parontaf sfetus, rellgion, sexual afenteUon, geneBc Informatlon, pollBce! bellefs, iepdsal, or because aJl �
<br />part ofan indtvfduaf's inoome ls derlved hom any puGllc asststatrce progrem. (Not alf prohl6Jted bases app/y to al! progiems) Persons wlfh c6sa6r716es who
<br />requlre altemaBve means for eommunfeedon of program Informa8on (Brellle, large pdn� au�ofape, eta) shou/d crontact USDA s TARGET Center at (202) 720-
<br />2600 {volce and TDDJ. To N/e a complain! of dfscr7minaBon, wdte to USDA, Assistent Secretery for CINf Rlghts, Ofltce o/the .4ss/stent Secrefary for Clvil R/gMs,
<br />1400 Ndependence Avenue, S. W., Stop 9410, Washington, DC 20250-8410, or caH toU-fiee at (es6) 532-8892 {English) nr (800) 877-8339 (TDD) ar (866) 377-
<br />8642 (EngAsh Federal-retay) or (800) 845-6138 (Spenish Federa!-relay). USDA is en equal opporhmlty provlder and emplo}rer.
<br />FSA-2319 (01-11-12) Page 2 of 2
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<br />6. ACKNOWLEDGMENT
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