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200707689 CCC-297 (08-18-04) Page 2 of 2 IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument this (h) S "!.~ day of (i) ~ ~"\~ k.o..tl"itL.- ,0) 2007 (year). if a corporation: FARM SERVICE AGENCY (k) Name a/Corporate (Mortgagee) (Owner) * (n) individual (Mortgagee) (Owner) * By ~.. g -A .F:J- ~>- ~..--J - (I) Duly Authorized Officer (0) individual (Mortgagee) (Owner) * FARM LOAN MANAGER (m) Title CORPORATE SEAL "Mortgagee" includes holder of any type of real estate lien. *Delete "Mortgagee" or "Owner." (p) STATE OF NEBRASKA (q) COUNTY OF HALL } ss. ACKNOWLEDGMENT: S::::::'r~ , On this (r) d day of (s) ~p"'r'i ",^,~~lL in the year (t) ~1 , before me, the undersigned, a Notary Public in and for said State, personally appeared (u) ~~R."'\"c:) ~ ~ .a'au_~~ 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. execute the instrument. J;GEJUAL NOTARY - Stale 01 Nebraska SHmEY Il SCHROEDER My Comm. Exp. Oct. 5. 2010 My commission expires (w) (SEAL)~ K~~ . (v) ~ry 9Ii.c_ IO-S"~DJt) (MM-DD-YYYY) NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 55213) and the Paperwork Reduction Act of 1995. as amendad. The authority for requesting the following information is 7 CFR Part 1436 and tha Commodity Credit Corporation Charter Act. 5 USC 714 et. seq. The information will be usad to determine eligibility for CCC IInancing for farm, storage and drying equipment. Fumishing the requested information is voluntary; however, without it CCC finanCing under the program cannot be provided. Failure to furnish the requested information will result in denial of CCC financing under this program. This information may be provided to other agencies, IRS, Department of Justice. or other State and Federal law enforcement agencies. and in response to a court magistrata or administrative tribunal. The provisions of criminal and civil fraud statutes. including 18 USC 286,287,371,641, 651, 1001; 15 USC 714m; end 31 USC 3729, may be applicable to the information provided. According to the Paperwork Raduction 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 0560-0204. 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, gatharing and maintaining the data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.