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CCC -297 (03- 23-12)
<br />if a corporation:
<br />By
<br />CORPORATE
<br />SEAL
<br />F o r e,„,. 1- ��RtJ►eES
<br />(k) Name of Corporate (Mortgagee) (Owner)-*
<br />Vie? 7(0;44
<br />(1) Duly Authorized Officer
<br />(m) Title
<br />"Mortgagee" includes holder of any type of real estate lien.
<br />*Delete "Mortgagee" or "Owner."
<br />(p) STATE OF J1/4. CASKR
<br />(q) COUNTY OF -4 A L1—
<br />A GENERAL NOTARY - State of Nebraska
<br />11 KATHERINE S. SCHULTE
<br />e .®! My Comm. Exp. May 23, 2013
<br />}
<br />201210380
<br />IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument
<br />this (h) day of (i) &
<br />w8� F•t- t.t —n�x�s 1-t TS
<br />(Ir} (Owner)
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<br />rJ rPl,. • „, �'°
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<br />• .i°
<br />(SEAL)
<br />{e) (Owner) *
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<br />ss, ACKNOWLEDGMENT:
<br />G) 2 `2(year).
<br />On this (r) o? (o day of (s) OC..f in the year (t) X70 /,.a. , before
<br />me, the undersigned, a Notary Public in and for said State, personally appeared (u) 1 0,4 e p L ) LcL,t
<br />personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are)
<br />subscribed to the within instrument and acknowledged to me that he /she executed the same in his/her /their capacity (ies), and
<br />that by his/her /their signature(s) on the instrument, the individual(s) or the person on behalf of which the individual(s) acted,
<br />execute the instrument.
<br />(v) Notary Public
<br />My commission expires (w) G15 - -.2 - �zo 13
<br />(MM - DD - YYYY)
<br />Page 2 of 2
<br />NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). The authority for requesting the information identified on this form is 7
<br />CFR Part 1436, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110 -246). The information
<br />will be used to obtain a Farm Storage Facility Loan Program severance agreement when there are real estate lien holders involving the land where a storage facility is to be
<br />located. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have
<br />been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA -14,
<br />ApplicantBorrower. Providing the requested information is voluntary. However, failure to famish the requested information will result in a determination of ineligibility for CCC
<br />financing under the Fann Storage Facility Loan Program..
<br />This information collection is exempted from the Paperwork Reduction Act, as it is required for the administration of the Food, Conservation, and Energy Act of 2008 (see Pub. L.
<br />110 -246, Title 1, Subtitle F - Administration..
<br />The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR
<br />COUNTY FSA OFFICE.
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