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20 1014G� 5, IN WITNESS WHEREOF, Mortgagee has executed this Agreement by signing on the (a) i day of (b) /� f‘%` , (c) 202). BY (d) TITLE (e) lJ"et -e A'e; 6. ACKNOWLEDGMENT STATE OF NEBS): ) COUNTY OFVPrs2i ) A This foregoing instrument was acknowledged/�before me this /9 day of . Ftbi-4 rt. , 2021, by / Jt..) .S'4 Q' (A�V-tr^ J (Duly Authorized Officer) U eft; f (Z' 9 4.1 C .1 � of jet-Ul-4 M S (01.. -Let j't7 C^ (Name of ortgagee) (Title) My commission expires: General Notary NOTE: The following statement is made In accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the information identified on this form Is the Consolidated Farm and Rural Development Act, as amended (7 U.S. C. 1921 at.l@g..). The Information will be used to determine eligibility and feasibility for loans and loan guarantees, and servicing of bans and loan guarantees. The information collected on this form may be disclosed to other Federal, State, and 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 the 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 may result in a denial for loans and loan guarantees, and servicing of loans and loan guarantees. The provisions of criminal and civi! fraud, privacy, and other statutes may be applicable to the information provided. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person Is not required to respond to, a collection of information unless It displays a valid OMB control number. The valid OMB control number for this Information collection is 0560-0237. The time required to complete this information collection Is estimated to average 30 minutes per response, including the time forreviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of informatlon. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. The U.S. Department of Agriculture (USDA) prohibits discrimination in ells programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, poildce/ beliefs, reprisal, or because all or pert of an ind/vlduars income is derived from any public asicogram(Not all prohibited bases apply ito ail Persons hdisabes w require a!enative means for communication of program Information ( . /ergo print, pe etc.) should contact USDA's TARGET et (2 2) 720- 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, (English Federal -relay) yor (800)op 9410, 845-6136 (Spanish Federal-relay).ton, DC 9410, USDArcall toll-free at is an equal opportunity provider and632-9992 lish) or employeer�) 877-8339 (TDD) or (866) 377- 8642 FSA -2319 (01-11-12) Page 2 of 2