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Signed <br />Lienor: <br />By: <br />Officer or Agent <br />200509362 <br />State of NX)Ul( S��' <br />County of <br />On <br />20 . <br />0� <br />W / ,r <br />20 Q before me, <br />appeared <br />personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is /are <br />subscribed to the within instrument and acknowledged to me that he /she /they executed the same in his /her /their authorized <br />capacity(ies), and that by his /her /their signature(s) on the instrument the person(s), or the entity upon behalf of which the <br />person(s) acted, executed the instrument. <br />WITNESS my hand and official seal, <br />Signature <br />,Signature of Notary <br />Affiant Known roduced ID ,. <br />Type of ID— <br />(Seal) <br />X NERAL NOTARY - State of Nebraska <br />STACEY RUZICKA <br />My Comm. &n. May 10, 2OOi <br />Page 2 <br />www.socrates.com ® 2004, Socrates Media, LLC <br />LF 136 - Rev. 04/04 <br />