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200707690 CCC-297 (08-18-04) Page 2 of 2 IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument this (h) l/ ;vl day of (i) ~&...- ,0) 2007 (year). if a corporation: ?o~ h I 1;(' hv'" WJ S (k) Name of Corporate (Mortgagee) (Owner) * ')( '~~~~~~,.L::/-' . (n) Individual (MarlgagaB) (Owner) 't (BJRRrnER) (0) Individual (Mortgagee) (Owner) * By (I) Duly Authorized Officer (m) Title CORPORATE SEAL "Mortgagee" includes holder of any type of real estate lien. (p) STATE OF (q) COUNTY OF *Delete "Mortgagee" or "Owner." .~/~ ~,,-_./ I-} <<.jJ J } ss. ACKNOWLEDGMENT: On this (r) tj-f!! day of (s) 0Yji.~.'711~ me, the undersigned, a Notary Public in and for said State, personally appeared (u) 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 individua\{s) acted. execute the instrument. GENERAL NOTARY. State 01 Nebraska RUTH TYMA Comm. ~. May 17. 2009 (SEAL) c-c--.. My commission expires (w) NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Redvction Act of 1995. as amended. The avthority for reqvesting the following information is 7 CFR Part 1436 and the Commodity Credit Corporation Charter Act. 5 USC 714 et. seq. The information will be vsed to determine eligibility for CCC finanCing for farm. storage and drying eqvipment. Fvmishing the reqvested information is volvntary; however. withovt it CCC financing vnder the program cannot be provided. Failvre to furnish tha requested information will resvlt in denial of CCC financing under this program. This information may be provided to other agancies. IRS. Department of Justice, or other State and Federal law enforcement agencies, and in response to a court magistrate or administrative tribvnal. The provisions of criminal and civil fravd statvles, inclvding 18 USC 286,287,371, 641, 651. IDOl; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided. According to the Paperwork Reduction Act of 1995, an agency may not condvct or sponsor, and a person is not required to respond to, a collection of information vnless it displays a valid OMS control nvmber. The valid OMS control nvmber for this informalion 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 sovrces. gathering and maintaining the data needed, and completing and reViewing the collaction of information. RETURN THtS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.