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). 00' 0 tt 5' 'I CCC-297 (08-18-04) Page 2 of 2 IN WITNESS WHEREOF, the undersigned parties hereto havli executed this instrument this (h) ~ P( day of (i) rY) ~~ , Oj20tJ 7(year), if a corporation: (I) Duly Authorized Officer ~!2::}' fofj)J,Vldual / (Owner) * (k) Name of Corporate (Mortgagee) (Owner) * By (m) Title CORPORATE SEAL "Mortgagee" includes holder of any type ofreal estate lien. *Delete "Mortgagee" or "Owner." (P) STATE OF Iv} d rt5 k e-/ (q) COUNTY OF ~ } ss. ACKNOWLEDGMENT: On this (r) d IJ p( day of (s) /fl ~~A-- in the yeaK (t) me, the undersigned, a Notary Public in and for said State, personally appeared (u) a d t-litu.'.d.., 4- 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 individuaUs) acted. execute the instrument. 'cA ~ .J;GENERAL NOTARY-State of Nebraska LANA K. MARET My COI1II\. ExP. JlI'lO 17. 2011 (SEAL) d1~ot1:~ -?L/I ~. 011 (MM-DD-YYYY) . . My commissi<;m expires (w) NOTE; The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the PapelWork Reduction Act of 1995, as amended. The authority for requesting the following information is 7 CFR Part 1436 and the CommOdity Credit Corporation Charter Act, 5 USC 714 et. seq. The information will be used to determine eligibitity for CCC financing for ferm, storage and drying equipment. Fumishing the requested information is voluntary; however, without it CCC financing under the program cannot be provided. Failure to fumish the requested information will result in denial of CCC financing under this program. This information may be provided to other agencies, IRS, Oepartment of Justice, or other State and Federal law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 use 286,287,371,641,651, 1001; 15 use 714m; and 31 use 3729, may be applicable to the information provided. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, end a person is not required to respond to, a collection of information unless it displays a vatid 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 data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFtCE.