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200702584 CCC-297 (08-18-04) Page 2 of 2 rb IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument this (h) /. ~ day of (i) em ~--- , 0) 2001 (year). if a corporation: FIRST STATE BANK (k) Name of Corporate (Mortga e) (Owner) * (n) Individual (Mortgagee) (Owner) * By (0) Individual (Mortgagee) (Owner) * .Prr>,,:::;r'j,::'nt (m) Title CORPORATE SEAL "Mortgagee" includes holder of any type of real estate lien. *Delete "Mortgagee" or "Owner." (P) (q) STATE OFII.\~.\1v-(}.S~O-> . COUNTY OF Bu.-WD"'\O } ss. ACKNOWLEDGMENT: On this (r) 13M day of (s) rr} 6.,r~ in the year (t) 2001 , before me, the undersigned, a Notary Public in and for said State, personally appeared (u) (jl~.d_ C. '1'..41".v flA~lliclfUt..f: I ' personally known to me or proved to me on the basis of satisfactory evidence to be the mdividual(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. execute the instrument. .j;GU4WUOTARr-Slateaf...... SEAL) J)MN IlIllME .~. . ~ e.mm. &,. NlIv. n. 211. ~}~,~ (v) Notary Public My commission expires (w) II-~~-IO (MM-DD-YYYY) NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 use 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is 7 CFR Parl1436 and the Commodity Credit eorporstion Charler Act, 5 USC 714 et. seq. The information will be used to determine eligibility for eee finencing for ferm, storege and drying equipment. Fumishing the requested information is voluntery; however, without it eee finencing under the program cannot be provided. Failure to furnish the requested information will result in denial of eee financing under this program. This information may be provided to other agencies, IRS, Deparlment of Justice, Or other Stete and Federsllaw enforcement egencies. end in response to a court magistrete or administrative tribunal. The provisions of criminal and civil freud stetutes, including 18 USC 286,287,371,641, 651, 1001; 15 use 714m; and 31 use 3729, may be epplicable to the information provided. According to the Paperwork Reduction Act of 1995, an agency mey not conduct or sponsor, end e person is not required 10 respond to, a collection of information unless it displays a valid OMS control number. The valid OMS control number for this information collection is 0560-0204. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the dala needed, 8nd completing end reviewing the collection of informalion. RETURN THtS COMPLETED FORM TO YOUR COUNTY FSA OFFtCE.