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<br />CCC-297 (08-18-04) <br /> <br />;).. tJ tJ 'g 0 7 ;;J. 7 3 <br /> <br />Page 2 of 2 <br /> <br />IN WITNESS WHEREOF, the undersigned parties <br />this (h) / L/ day of (i) <br /> <br /> <br />, 0;;;) CO f (year). <br /> <br />if a corporation: <br /> <br />By <br /> <br />(l) Duly A uthorized Officer <br /> <br />-M · <br />(( ~J . <br />. I)Individua=~8) (Owner) * <br />Jefl R Dibbern ~ <br />.-1 JAAA..it. <br />(0) Individual (Uertgagf!s) (Owner) * <br />Verna F Dibbern <br /> <br />(k) Name of Corporate (Mortgagee) (Owner) * <br /> <br />,.--- <br /> <br />(m) Title <br />,~~i. <br />\~ " <br /> <br />___~~..2".;.-. <br /> <br />CORPORATE <br />SEAL <br /> <br />"Mortgagee" includes holder of any type of real estate lien. <br />*Delete "Mortgagee" or "Owner." <br /> <br />(P) STATE OF <br />(q) COUNTY OF <br /> <br />NfL/; ruJ~ <br />~ <br /> <br />} <br /> <br />ss. ACKNOWLEDGMENT: <br /> <br />On this (r) I '-I day of (s) tlu. ~ _ in the ye~r (t) 2.dr1X" , before ( <br /> <br />me, the undersigned, a Notary Public in and for said State, personally appeared (u) Ijer r'l 1:. (J. bbe;-;-cr;;J1...f; F f) b~r'1 <br />personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is <br />(are) subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her/their capacity <br />(ie~1~n..QJhaJ by his/her/their signature(s)' on the instrument, the individIJal(s) or the, perspn on behalf of which the <br />individual(s) acted. execute the in!ttr\Jm '. tll:llr:DJ.I . ~''''A c& <br />'* 6 QE.~ NOTARY_ Of NetIruka <br /> <br />~ ..,c~A::~r201t (SEAL) AA-If ~ <br />, (~) ~otary Public <br /> <br />9uILP 17 2{)/1 <br />(MM-DD- YYYY) <br /> <br />My commission expires (w) <br /> <br />NOTE: The following state/TI/Jnt is made in eccordanoe with the Privacy Act of 1974 (S USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for 19questing <br />the followinglnformeoon is 7 CFR Perl 1436 and the Commodity Credit eOlporation Charter Act, 5 USC 714 et. seq, Tha information will be used to detarmine e//flibHity for <br />CCC financing for farm, storege and drying equip/TI/Jnt. Fumishing Ihe requested information Is VOluntary; however, without it eee financing under the program cannot be <br />provided. Feilure 10 fumlsh the 19quasted information wUJ result in denial of cee financing under this pfOf/rem, This Information mey be provided to other agencl8s, IRS, <br />Depart/TI/Jnt of Justice, or other Stete and FlIdIIllIllew enforcement egencl8s, 8nd in IQPOnse to a court m8flistlllte or 8dmlnlstrativa tribunal, The provisions of criminaf 8nd <br />civil fraud statutas, incJuding18 use 286, 267, 371, 641, 651, 100/; 15 USC 714m; 8nd 31 use 3729, may be epplicable to thelnformeoon provided, <br /> <br />According to the Paperwork Reduction Act of 1995, an 8gency may not conduct or sponsor, and 8 person is not required to respond to, a coflllCtion of Information unless it <br />displays a valid OMB control numbar. The valid OMB control number for this Inform8tion collection ;s OS60.0204, The time required to complete this information collection is <br />estimated to average 15 minutes par response, including the time for reviewing instructions, se8rchmg existing dat8 sources, gathering and maint8inlng the dala n/J/Jded, 8nd <br />completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE. <br />