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Farm Credit Services of America <br />APPLICANT NAME VERIFICATION FORM <br />201801998 <br />FORM 6441 (05 -2013) <br />Daniel <br />Instructions: Please view your most recently issued, unexpired driver's license to complete this form. <br />Upon completion, sign, date and return this form to your Farm Credit Services of America office. <br />Complete one form for each individual or each partner in a general partnership when: <br />1. An individual (including a sole proprietorship) applies for credit, or <br />2. A generalpartnership applies for credit and does not have a written partnership agreement. <br />(Submit a separate form for each partner.) <br />� e ( Sepinert «rO n�-G S NebrgSkq <br />Applicant's Na a (First, Middle, Last) Driver's License State of Issuance <br />(Exactly as it appears on your most recently issued, unexpired driver's license.) <br />"S oa llo /a.d r, <br />Driver's License Expiration Date <br />Driver's License Number <br />Complete Section I <br />The undersigned applicant represents and warrants to Farm Credit Services of America, PCA and /or <br />Farm Credit Services of America, FLCA that the information set forth above is true and correct and that <br />the above information was transcribed from the applicant's most recently issued unexpired driver's <br />license. The undersigned applicant hereby agrees to indemnify and hold Farm Credit Services of <br />America, PCA or Farm Credit Services of America, FLCA harmless from any Toss or damage caused by <br />or resulting from a breach of the foregoing representations and warranties. <br />to <br />I <br />: & . l ►.. ■:» 0 ) log /02 01% <br />Applicant Date <br />Sign <br />