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WARNING TO HOMEOWNER <br />YOU ARE REQUIRED TO DO THE FOLLOWING: <br />1. COMPLETE AND RETURN THIS FORM TO THE PERSON WHO ASKED FOR IT WITHIN TEN <br />DAYS AFTER THE DATE OF THE POSTMARK OF THE REQUEST. <br />2. IF YOU DO NOT COMPLETE AND RETURN THIS FORM WITHIN THE TEN DAY PERIOD, YOU <br />HAVE TO PAY THE EXPENSES INCURRED IN GETTING THE INFORMATION. <br />3. IF YOU DO NOT LIVE AT THE SITE OF THE IMPROVEMENT, YOU MUST POST A COPY OF <br />THIS FORM IN A CONSPICUOUS PLACE AT THAT SITE. <br />YOU ARE NOT REQUIRED TO BUT SHOULD DO THE FOLLOWING: <br />1. COMPLETE AND POST A COPY OF THIS FORM AT THE PLACE WHERE THE IMPROVEMENT <br />IS BEING MADE, EVEN IF YOU LIVE THERE. <br />L K <br />Jca K Oseka Dat <br />e <br />This instrument was prepared by: <br />Exchange Bank <br />1204 Allen Drive, PO Box 5793 <br />Grand Island, NEBRASKA 68802 <br />308 -382 -2900 <br />Exchange Bank <br />1204 Alien Drive, PO Box 5793 <br />Grand Island, NEBRASKA 68802 <br />STATE OF NEBRASKA, Hall County ss: <br />The i egoing instrument was acknowledged before me this day of <br />b J inn K Oseka. <br />Witness ify hand and notarial seal at min said County, the date <br />aforesaid. <br />My Commission Expires: April 7, 2016 <br />IDS. ma <br />Page 2 of 2 <br />otary Public Daniel Roth <br />201306705 <br />Loan Number: 201125212 <br />Dat <br />e <br />