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CCC - 297 (03- 23 -12) IN WITNESS WHEREOF, the undersigned parties h reto have executed this instrument this (h) , day of (i) CORPORATE SEAL (p) STATE OF NEBRASKA (q) COUNTY OF HALL GENERAL NOTARY S GHR O Nebraska My Comm. Exp. October 5, 2018 } (SEAL) My commission expires (w) (n) Individual (Owner) (o) Individual (Owner) ss. ACKNOWLEDGMENT: T�!` �� On this (r) 1 day of (s) - ,,14,ay. Ae..`'/ in the year (t) �O 1 L , before me, the undersigned, a Notary Public in and for said State, personally app@ared (u) OAtitA .I E. i- 44.1- 1144■0 4.84144444 L personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) (4A t cus4 subscribed to the within instrument and acknowledged to me that he /she executed the same in his/her /their capacity (ies), and that by his/her /their signature(s) on the instrument, the individual(s) or the person on behalf of which the individual(s) acted, execute the instrument. G) a l0 1(p (year). Q. It (kvaaid„ (v) ary Public / -S -I (MM- DD - YYYY) 201600219 Page 2 of 2 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 CFR Part 1436, the Commodity Credit Corporation Charter Act (15 U.S. C. 714 of seq.), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110 -246). The information will be used to obtain a Farm Storage Facility Loan Program severance agreement when there are real estate Tien holders involving the land where a storage facility is to be located. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have 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, Applicant/Borrower Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility for CCC financing under the Farm Storage Facility Loan Program.. 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. 110 -246, Title I, Subtitle F — Administration.. 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 COUNTY FSA OFFICE.