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200909989 CCC-297 (08-18-04) Page 2 of 2 IN WITNESS, (WHEREOF, the undersigned parties ereta have executed this instrument Q~ this (h) day of i if a corporation: (k) Name of Corporate (Mortgagee) (Owner) * (n) Individual {7bfm-fg~ (Owner) BY (o) Individual (Mortgagee) (Owner) (t) Duly Authorized Officer .-._...__..u.._._..f_ (t11) Title CORPORATE SEAL "Mortgagee" includes holder of any type of real estate lien. *Delete "Mortgagee" or "Owner." (p) STATE OF } ss. ACKNOWLEDGMENT: (g) COUNTY OF On this (r) ~ day of (s) E ~ in the year (t) before me, the undersigned, a Notary Public in and for said State, personally appeared (u) A lTA 5..rr i 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 individual(s) acted, execute the instrument. GfNERAI NOTARY • 5tafe of Nebraska (SEA L) L SHEl1EY K SCHROEDER V) of Pub 1511- My Cnmm. Exp. Oct. 5, 2DIQ My commission expires (w) l © `S _ c=~C.~ I C~ (MM-DD-YY)'Y) 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 at. seq. The information will be used to determine eligibility for CC financing for farm, storage and drying equipment. Furnishing the requested Information is voluntary; however, without it CCC financing under the program cannot be provided. Failure to furnish the requested information will result in denial of CCC financing under this program. This information may be provided to other agencies, IRS, Department 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 USC 266, 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 OMB control number. The valid OMB control number for this Information collection is 0560-0204. The time required to complete this information collection Is estimated to everege 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.