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5. IN WITNESS WHEREOF, Mortgagee has executed this Agreement by signing on the (a) day
<br />rcnv
<br />of (b) , .
<br />(c) 20�
<br />BY (a9
<br />TITLE (e)
<br />STATE OF NEBRASKA )
<br />COUNTY OF Fit n K I14 )
<br />This
<br />foregoing
<br />instrument was
<br />My commission expires:
<br />1
<br />GENERAL NOTARY -State of Nebraska
<br />NANCY MIETZNER
<br />My Comm. Exp. June 25, 2015
<br />. ACKNOWLEDGMENT
<br />acknowledged before me this day of
<br />,7@001
<br />(Duly uthorized Officer)
<br />fh 7 Ga _e Fe§lre
<br />(Name Mor gagee)
<br />201404773
<br />NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552e - as amended). The authority for
<br />requesting the information identified on this form is the Consolidated Farm and Rural Development Act, as amended (7 U.S.C.
<br />1921 gj. sea.). The information will be used to determine eligibility and feasibility, for loans and loan guarantees, and servicing of
<br />loans and loan guarantees. The information Collected an this form may be disclosed to other Federal, State, and local government
<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 furnish 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 individual's 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 Civr7 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 />86442 (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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