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5. IN WITNESS WHEREOF, Mortgagee has executed this Agreement by signing on the (a) 3 0
<br />of (b)
<br />STATE OF NEBRASKA
<br />r , 2014, by
<br />(Title)
<br />My commission expires:
<br />of
<br />GENERAL NOTARY - State of Nebraska
<br />PATRICK J. McGUIRE
<br />My Comm. Exp. Sept. 26, 2014
<br />COUNTY OF H,41,L- )
<br />This foregoing instrument was acknowledged before me this .3d
<br />! C H44 ,o oa, A,So
<br />(Duly Authorized Authorized Officer)
<br />G Y ikni6OG - ,444NJC_
<br />(Name of Mortgagee)
<br />201 4041 38
<br />day of
<br />General Notary
<br />day
<br />NOTE: The following,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 identified on this form is the Consolidated d Farm and Rural Development Act, as amended (7 U.S.C.
<br />1921 et seq.). The information will be used to determine eligibility a feasibility for loans and loan guarantees, and servicing of
<br />loans and loan guarantees. The information collected on this form may be disclosed to other Federal, State, and local govemment
<br />agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or
<br />regulation and/or as described in the applicable. Routine- Uses identified in. the System of Records Notice for USDA/FSA -14,
<br />Applicant/Borrower. Providing the requested information is voluntary. However, failure to fumish the requested information may
<br />result in a denial for loans and loan guarantees, and servicing of loans and loan guarantees. The provisions of criminal and civil
<br />fraud, privacy, and other statutes may be applicable to the information provided.
<br />According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
<br />respond to, a collection of information unless It displays a valid OMB control number. The valid OMB control number for this
<br />information 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 TO YOUR COUNTY
<br />FSA OFFICE
<br />The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and
<br />where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or
<br />part of an individuars income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who
<br />require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-
<br />2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights,
<br />1400 Independence Avenue, S W., Stop 9410, Washington, DC 20250 -9410, or call toll -free at (866) 632 -9992 (English) or (800) 877 -8339 (TDD) or (866) 377-
<br />8642 (English Federal-relay) or (800) 845 -6136 (Spanish Federal - relay). USDA is an equal opportunity provider and employer.
<br />FSA - 2319 (01- 11 -12) Page 2 of 2
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