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<br />Cenifirnra of Caaveyonee orhe. rhan Deeds ai Real Enare _ ~~ <br />This Statement is Confidential and Available <br />to Toxing.Officials Only <br />This form pursuant to Section 7b-214 R.R.S., ;4.43, as amended by the 75th Session of the Nebraska i~ <br />Legislature, must he completed and attached to every mortgage or other conveyance of real estate <br />estept deeds of veal estate before such instrument is filed Cor recording. <br />Parties to Instrument...~•"°'~'~'..., -, -,., _ ..,,m .................................................... <br />_...f x-.., ....;,.RI..,,. .,..;•::BT:.~..~.,. r; 'in.w.ci =rvice=, <br />^'~ , ~."" ..... l3uok Pa e <br />Type oC 4nstrumentgEai..~~T.t;`~. ~•:D.°. ~n;...._..._... Date :....-...... _ g <br />Consideration paid (or Real Es[ate .........................s7,OCa.6,.J.a <br />Certification <br />1. (he undersigned, having personal knowledge of [his transaction. cerUfp that the foregoing is true ~ <br />:tnd correct. ! <br />_ __, <br />Signanu~. k~........._....... <br /> <br /> <br />