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<br />CCC-297 (08-18-04) <br /> <br />200603873 <br /> <br />Page 2 of 2 <br /> <br />. IN WITNESS ~HEREOF. the undersigned partie)ltheret? have executed this instrument <br />thIS (h) / c;-t: day of (i) _____':\.1 p,. . ( <br /> <br />, (j) 6)00 (. (year). <br /> <br />if a corporation: <br /> <br />(k)Name of Corporate (Mortgagee) (Owner) * <br /> <br />~ ~{2-1'/v.;/,/.. ,d' ,JIRJi ' <br />(n) Individual (Mortgagee) (Owner) * <br /> <br />By <br /> <br />(0) Individual (Mortgagee) (Owner) * <br /> <br />(l) Duly Authorized Officer <br /> <br />(m) Title <br /> <br />CORPORATE <br />SEAL <br /> <br />"Mortgagee" includes holder of any type of real estate lien. <br />*Delete "Mortgagee" or "Owner." <br /> <br />(p) STATE OF A 1Z. hr Q~ *-"'--' <br />(q) COUNTY OF I+li__\ \ <br /> <br />} ss. ACKNOWLEDGMENT: <br /> <br />day of(s) ~Af;' \ <br /> <br />me, the undersigned, a Notary Public in and for said State, personally appeared (ui tr\.(:. r ((, I \ "'" A ~ +e , k-..., , <br />personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is <br />(are) subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her/their capacity <br />(ies), and that by his/her/their signature(s) on the instrumeIlt, the individual(s) or the person on behalf of which the <br />individuaUs) acted. execute the instrument. '. . <br /> <br />On this (rJ. <br /> <br />I~ <br /> <br />in the year (t) ~()O '" <br /> <br />, before <br /> <br />I <br /> <br />GENERAL NOTARY - Stale of Nebl'llSka <br />DOREEN D.~E~ .~/ <br />My Comm. Exp. -o~' ~.~ J' <br /> <br />(SEAL) <br /> <br />~, C, A <br />\~ ~.-,A ~ ~cIk'-~,,-r- <br />(v) Notary Public <br /> <br />My commission expires (w) <br /> <br />o IJ- 0 <{ - :;;LooY <br />(MM-DD-YYYY) <br /> <br />NOTE: <br /> <br />Th9 following stat9m9nt Is mad91n accordanCfi/ wfth th9 Privacy Act of 1974 (5 use 552a) and th9 Pap9rwork Roouctlon Act of 1995. as am9nd9d. The authority for requ9stlng <br />th9 following Information Is 7 CFR Part 1436 and th9 Commodity Cr9dit Corporation Chart9r Act. 5 USC 714 9t. s9q, Th9 information will be used to determine eligibility for <br />eee financing for farm, storage and drying equipment. Fumlshlng the requested Information is voluntary; however, wfthout ft CCC financing und9r the program cennot be <br />provided. Feilure to furnish the requested informetlon will result in denial of eee financing under this program. This information may b9 provid9d to oth9r ag9nci9S, IRS, <br />D9partm9nt of Justic9, or Oth9r Stat9 and F9d9rallaw 9nforc9m9nt agfi/nci9s. and In responS9 to a court magistrate or administrative tribunal. The proVisions of criminal and <br />civilfraud statutes, Including 18 USC285, 287.371,541,651. 1001; 15 USC;714m; and 31 USC 3729. may b9 applicable to the Information provided. <br /> <br />According to th9 Pap9rwork R9duction Act of 1995. an ag9ncy may not conduct or sponsor, and a person Is not required to respond to. a collection of information unless It <br />displays a valid OMB control number. The valid OMB control number for this Information cOll9ction is 0560-0204. Th9 tim9 required to complete this information collection is <br />9stlma19d to aV9rag9 15 minut9S per response, including the time for reviewing instructions, searching existing data sourc9S. gath9rlng and maintaining th9 data n99d9d, and <br />COmpl9tlng and revi9wing th9 coll9ction of information, RETURN THfS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. <br />