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201206353
<br />5. IN WITNESS WHEREOF, Mortgagee has executed this Agreement by signing on the (a)
<br />of (b) Aucrust , (�� Z�J.2 �
<br />BY (c�
<br />TITLE (e)
<br />6. ACKNOWLEDGMENT
<br />STATE OF NF3BRASKA )
<br />COUNTY OF �r. )
<br />This foregoing instrument was acknowledged before me this
<br />lst day
<br />lst day of
<br />A1�CJ]�G'f' , 2012, by
<br />Du y Authorized Officer)
<br />of Joe Allan Revocable Su�v.iuo�s Trust dated
<br />Title) ` (Name of Mortgagee) February 22, 2011
<br />My commission expirea:
<br />a�i
<br />GEhfERAI NOTARY - Siate of Nebraska
<br />BRUCE I. SMITH
<br />h� Comm. Eltp..�ly 7, 2014
<br />General N ary
<br />The fol/owing statement is made in accordance with the Privacy Act of 1974 (5 U.S. C. 552a - as amended). The authority for
<br />requesting the information Ident�ed on this form is the Consolidated Farm and Rural Deve/opment Act, as amended (7 U. S. C.
<br />1921 �. �.). The information will be used to determine eligi6ility and feasibility for loans and Ioan guarantees, and servicing of
<br />loans and loan guarantees. The information co//ected on this form may be disc/osed to other Federal, State, and /oca/ govemment
<br />agencies, Triba/ agencies, and nongovernmenta/ entities that have been authorized access to the information by statute or
<br />regulation and/or as descnbea' in the applicab/e Routlne Uses ident�ed in the System of Records Notice for USDA/FSA-14,
<br />Applicanb8orrower. Providing the requested information Is vo/untary. However, failure to fumrsh the requesfed information may
<br />result /n a denial for loans and loan guarantees, and servicing of /oans and loan guarantees. The provisions of crimina/ and civil
<br />fraud, privacy, and other statutes may be applicable to the informatlon provided.
<br />According to the Paperwork Reduction Act of 9995, an agency may not conduct or sponsor, and a person is not required to
<br />respond to, a collection of informatlon un/ess it disp/ays a valid OMB contro/ num6er. The valid OMB contro/ number foi this
<br />informaBon collection is 0560-0237. The time required to complete this information collection is estimated to average 30 minutes
<br />per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
<br />needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM t0 YOUR COUNTY
<br />The U.S. Depertment o/Ag�lcu/ture (USDA) prohi6lts dJsraiminadon ln all its piograms and activiHes on the basis of race, co/o� natlona/ origin, age, disability, and
<br />where appllcab/e, s�c, marital status, fam111a1 status, parenta/ status, reltgfon, �xual orientation, genedc irHormaBon, polltical 6eUefs, ieprisal, or because all a
<br />part of an lndlvidual's ir�come is dedved fiom any publlc asslstance progrem. (Not e/l prohiblted bases app/y to a11 prog�ems.) Persons with �sabiliBes who
<br />req�ure a/temative means for communicaBon o/ program i�ormadon (Brailie, large pdnt aurpotape, etc.) should co�act USDA s TARGET Center at (202) 720-
<br />2600 (voice snd TDD). To flle a complaint of dlscrim/nadon, write to USDA, Asslstenf Secretary for Clvil R/ghfs, OflJce of fhe Asslstartt Secretary for Civil Rights,
<br />1400/ndependence Avenue, S. W., Stop 3410, Washington, DC 2025Q-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDO) or (866) 377-
<br />8642 (Engllsh Federal-relay) or (800) 845-6136 (Spanish Federalae/ay). USDA is an eque/ opportunity prov/der and employer.
<br />FSA-2319 (01-11-12) Page 2 of Z
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