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• WV OZ: S :BJ SIB /E3 /Zi 30L9S585:•Ix <br />CCC - 297 (03- 23 -12) <br />IN WITNESS WIiEREOF, the undersigned parties!h reto have executed this instrument <br />this (tl) - CRq day of (i) C be-r <br />ifa corporation: <br />iJ -- <br />U S BANK HOME MORTGAGE <br />(t,) Nwne of Corporate (Mortgagee) <br />BY 4-_)(1_11e.4 1.. 1 Qokei <br />R) Duly Authorized Officer <br />G 4i ev r4 a Z <br />( nt ) Title <br />CORPORATE <br />SEAL <br />(p) STATE OF A t"ct.c.k. F, <br />(q) COUNTY OF I e_4c <br />On this (i) o � r day of (s) f� .G�ri"► b .Q - f in the year (1) -aO 1 S before <br />me, the undersigned, a Notary Public in and for said State, personally appeared (e) Lon Jones , <br />personally known to me or proved to me on the basis of satisfactory evidence to be the individuals) whose name(s) is (are) <br />subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her /their capacity (ies), and <br />that by his/her /their si2nature(s) on the instrument, the individual(s) or the person on behalf of which the individual(s) acted, <br />execute the instrument. <br />OFFrctt.• t c....... <br />LOF.' <br />NOTAP' • • NTUCKY <br />My ' t...::: vrit 16, 2017 <br />} ss. ACKNOWLEDGMENT: <br />(SEAL) �g 4 (0.5 <br />My commission expires ( : :/ 0 L( / 10 — J }. <br />NOTE: The following statement is made in accordance with the Privacy Act of 7976 (5 USC 552a - as amended). The authority for requesting the information identified on this form is 7 <br />CFR Part 1436. the Conmtaddy Credit CorporaSon Charter Act (15 U.S.C. 714 et seq.), and the Food, Conservation, and Energy Act of 2008 (Pub. L 110 - 24'6). The information <br />will be used to obtain a Farm Storage Facddy Loan Program severance agreement when there are real estate lien holders involving the land where a storage facility Mb be <br />located. The information collected on this dorm may be disclosed to other Federal, State, Localgovernrnenl egences, Tribal agencies, and nongovemmenta/ entities that have <br />been authorized access to the information by statute arrogated; and/or as described in applcable Routine Uses idonLlied in the System of Records Notice for USOA/FSA -14, <br />Applicant/Borrower.. Providing the requested information is voluntary. However, ferlure to furnish the requested information mil result in a deterrrx'nation of ineligibitdy for CCC <br />financing under the Fann Storage Facility Loan Program.. <br />This information collection is exempted from the Paperwork Reduction Act, as it is required for the adrninis,Yation of the Food, Conservation, and Energy Act of 2008 (see Pub. L. <br />110.246, TM f, Subtitle F— Administration.. <br />The provisions of eppropdate criminal and civil fraud, privacy, and other statutes maybe applicable to the information provided. RETURN THIS COMPLETED FORM 70 YOUR <br />COUNTY FSA OFFICE <br />OFFICIAL SEAL <br />LORI JONES <br />NOTARY PUBLIC - r.; :'t'UCKY <br />STATE -A? E <br />My Comm. Exam • u 18, 2017 <br />Ir ,. <br />2 016 -0-1 9 <br />� z�s <br />Q) ZD1, (verrr). <br />(v) Notary Public <br />(Alri -DD -} fl )) <br />