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201001371 CCC-297 (08-18-04) Page 2 of 2 IN WITNESS WHEREOF, the undersigned parties hereto have executed this instrument this (h) _,,, / `~ f ~ ,_ __ _ __ day of (i) ~ G)-~- (Year). if a corporation: THE STATE BANK OF H (k) Name of rporai ~y (n) Individual (Mortgagee) (Owner) (o) Individual (Mortgagee) (Owner) '' w ~ ~ ~.; ., ,~ CORPORATE ~. . i',~u `'~~'`"~' ~ ~ ~ SEAL ,~.~ . ~ Y ._ ~ ~ _^~. t rs '~ "Mortgagee" includes holder ofaify"type of real estate lien. *Delete "Mortgagee" or "Owner." (p) STATE OF (q) COUNTY OF ss. ACKNOWLEDGMENT: On this (r) ~ ~ f day of (s) in the year (t) ,before me, the undersigned, a Notary Public in and for said State, personally ppeared (u) , personally known to me or proved to me on the basis of satisfactory evidence to be the dividual(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) . _._. a~ie~; ex`eciile Elie iristrurtient. - GENERAL NOTARY• State of Nebraska ll ~ NaNCrr nnrr=rzru~ ) My Comm.Exp.June25,2Q1~, tary ublic My commission expires (w) 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 repuesd'ng • the following informahon is 7 CFR Part 1436 and the Commodity Credit Corppratipn Charter Act, 5 USC 714 et, seq. The informab~on will be used ro determirre eligibility for CC finanGng for farm, storage and drying equipment. Furnishing the requested information !s voluntary; however, without it CCC finandng under the program Cannot be provided. Failure to furnish the requested information will result in denial o(CCC financirrg under this program. This information maybe provided mother agencies, IRS, Department of Justice, or other State and Federal law anforoement agencies, end In response [o a court magistrate or administrah'va tribunal. The provisions of criminal and civil /raud statutes inGuding 18 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, maybe applicable ro thB infprmation provided. According h) the Paperwork Reduction Act of 1995, an agency may rrot Conduct ar sponsor, and a person is not required ro respond ro, a Collection of information unless It displays a valid OMB conhol number. The valid OMB Conh'pl number for th/s Information collection is 0560-0204. The time required to Complete this information collection is estimated ro average 15 minutes per response, including the time for reviewing instruch'ons, searching existing data sources, gathedrrg arrd maintaining [he data needed, and completiYrg and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFIGE.