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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 />OK .C104Qt <br />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 Allen Drive, PO Box 5793 <br />Grand Island. NEBRASKA 68802 <br />STATE OF NEBRASKA, Hall County ss: <br />The f oinrt instrument was owledged before me this Df" day of <br />� .��% b K Ose <br />Witness my ht:'and notarial seal at n said County, the date <br />aforesaid. <br />My Comnite5ion Lxpires: April 7, 2016 <br />IDS, Ina <br />Page 2 of 2 <br />Notary Public Daniel Roth <br />20130670 <br />Loan Number: 201125211 <br />Dat <br />e <br />