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CCC.297 (08-18.04) ~ 00 go 1;). ,1 Page 2 of 2 IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument this (h) Ilf day of (i) 7 , OJ .760r (year). if a corporation: DIBBERN FAMILY FARMS, INC. (k) Name of Corporate (M81't~lJ8) fOll'IlIS1') "'(Borrower) By ~ D~ , , Duly Authorized Officer """">,:""",,,,~~,,:t;::, (n) individual (Mortgagee) (Owner) '" (0) individual (Mortgagee) (Owner) '" (m) Title CORPORATE SEAL "Mortgagee" includes holder of any type of real estate lien. "'Delete "Mortgagee" or "Owner." Ip) STATEOF ~p (q) COUNTY OF ~ } ss. ACKNOWLEDGMENT: On this (r) / ~ day of (s)" ill the year (t)c1t /?, before me, the undersigned, a Notary Public in and for said State, pers ly appeared (U)~ J:::J.:i- personally known to me or proved to me on the basis of satisfactory evidence to be 'the indi Idual(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 hislher/their signature(s) on the instrument, the individual(s) or the person on behalf of which the . individualls) acted.-execute the instrument. -' --~- - J;8RM. NOTARY - SlIfe.,...... , SIfARON BONSACI( at, Comm. Exp. Sept. 21, 20lII \ ' _ilU.~ "I I, (v) Notary Public o,q/~ {/ota7f" (MM-DD-Y YY) Mt~ (SEAL) My commission expires (w) NOTE: The following statement is made In accordanO/l with the Privacy Act of 1974 (5 USC 552a) and the Prlperwork Raduction Act of 1995, as amended. The authority for requesling the followlnQ information is 7 CFR Part 1436 and the Commodity Credit Corporalion Charter Act. 5 USC 714 el. seq. The information will be used to determine eligibility for cce financing for farm, slorage and drying equipment. Fumishing the requested Information is vo/unlary; however. without it eee financing under the program cannot be provided. Feilure to furnish Ihe requesl/ld information wltl result in denial of eee financing under this program. This information may be provided to other agencies, IRS. o..partmenl of Juslice. or other State and Federal law enforcement agendas, and in response to a court magistrate Or administrative tribunal, The provisions of criminal and civil fraud slalutes. including 18 use 286, 287. 37t, 641, 651, 1001; 15 use 714m; and 31 use 3729. may be applicable to Ihe Information provided. According to the Paperwork Reduction Act of 1995, an aQlmay 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 velld OMS control number for this information collection is 0560-0204. The time required 10 complete this information collection is eslimal/ld to averaQe 15 minutes per response, including the time for reviewing instructi<>ns, .arching existing data sources, gethering and mainteining the data n/l/lded, and completing and reviewing the collection of information, RETURN THfS COMPLETED FORM TO YOUR eOUNTY FSA OFFICE.