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200804803 CCC-297 (08-18-04) Page 2 of 2 IN WITNESS WHEREOF, the undersigned parties ereto have executed this instrument this (h) .;;) 8 .,.~ day of (i) cU+ , O)~O~ (year). if a corporation: (k) Name afCorporate (Mortgagee) (Owner) ... Cj., ~liff(~~~ 'm>] r~L 0~ '~nkle . Borrower (I) Duly Authorized Officer Borrower By (m) Title CORPORATE SEAL "Mortgagee" includes holder of any type of real estate lien. "'Delete "Mortgagee" or "Owner." (p) STATE OF (q) COUNTY OF o 't. ~eA-~<.A- \\A-c...t- } SS. ACKNOWLEDGMENT: " ~ ...~ f\f\ On this (r) <:::::;7- day of (s) 'v \ rt~t+ in the year (t) ~<.::l Y' , before J me, the undersigned, a Notary Public in and for said State, personally appeared (u) 2t1...ulltl.o L ~M~I o.\t.r. \. -. ::t~I"'" ~ J"~ 'Olt..<.t... 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 behaif of which the individual{s) acted. execute the instrument. J;GPERAL MOlAR\' - stale III Nebsaska SHEllEY K. SCHIlOtoER If:: MtComm. Exp. OcU. 2010 (SEAL)(' Q.Q.~ My commission expires (w) , . (0..$-..).0/0 S~K s.~ (MMDD-YYYr"r--- NOTE: The following statement is made in accordance with the PrivaCy Act of 1974 (5 usc 552a) and the Paperwork 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 eligibility for CCC financing for farm. storege end drying equtpment. Fumishing the requested information is VOluntary; however, without it eee financing under the progrem cannot be provided. Failure to furnish the requested information will result In denial ofcee financing under this program. This information may be provided to other agencies. IRS. Department of Justice. or other state and Federal law enforcement egencies. and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286,287,371,641, 651. 1001; 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 conduct or sponsor, and a person is not required to 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 avarage 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 OFFICE. o.