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• 4 202104029 CCC -297 (12-21-17) Page 2 of 2 IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument this (h) 3 day of (i) if a corporation: (k) Name of Corporate (Mortgagee) By (1) Duly Authorized Officer Y7' (m) Title CORPORATE SEAL (p) STATE OF 065 (q) COUNTY OF ///""'" 1.-1‘JS On this (r) Lprd day of (s)v�� in the year (t) , before me, the undersigned, a Notary Public in and for sal State, personally appeared (u) 57274 jG� • okAc� personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) 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, , a) G 0 ! (year). } ss. ACKNOWLEDGMENT: execute the instrument. (SEAL) XENERAL NOTARY - dais*, Worm flea My commission expires (w) (v) Notary Public Of - 05 (MM-DD-YYYY) 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 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to determine eligibility to participate in and receive benefits under the Farm Storage Facility Loan Program through documentation of a severance agreement when there are real estate lien holders involving the land where a storage structure 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 to participate in and receive benefits under the Farm Storage Facility Loan Program. This information collection is exempted from the Paperwork Reduction Act, as specified in the Agricultural Act of 2014 (Pub. L. 113-79, Title l Subtitle F. Administration). The provisions of criminal and civil fraud, privacy and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.