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� � d ,�`g � r CCC-297 (OS-18-04) 2 0110 f 5 0 3 Page 2 of 2 IN WITNESS WH�EREOF, the undersigned parties hereto have executed this instrument this (h) o�--? = day of (i) eq c� � c�st , G) �?i� // (year). if a corporation: FARM CREDTT SERVICES OF AMERICA (k) Name of Corporate (Mortgagee) (Owner) '� � By ��.--� � • +� (l) Duly Authorize Officer C or � � ,� G�-G. �, y Q.�La.. � (m) gitle PATRICK J 1KCGUIRE OCABLE LTVING TRUST PATRICK J MCGUIRE, TRT7STEE (OWNER) CO�� SEAL "Mortgagee" includes holder of any type of real estate lien. '�Delete "Mortgagee" or "Owner." (p) 5TATE OF ��¢��S�A (q) COUNTY OF /JAII. } ss. ACKNOWLEDGMENT: (SEAL) ��p�, � S�e oi Nebraska �pTM�p►{dE S. 3GHUL1'� � My commission expires (w) ��+-�d�u:�, �e��u� (v) Notary Public `fr�1� -,�', �o (MM-DD-YYYY) The following statement is made In acxordance with the Pirvacy Act of 1974 (5 USC 552a) and fhe Papervvork Redudion Ad of 1995, as amended. The aufhorfry Por requestrng the following informallon !s 7 CFR Part 1436 and the CommodRy CredR CorpoiaUon Charter Ad, 5 USC 714 et. seq. The informaUon wr71 be used to determine ellgi6tltty for CCC financing for fam, storage and drying eqWpmenk Fumishing the requested lnformallon Is wluntary; however, wrThout it CCC 8nancing under the progiam cannot be provided. Fallure to fumish the requested intormatlon w�71 resuft in denlal of CCC flnanctng under this program. This informatlon may be provlded to other agendes, IRS, Department of JusUce, or other State and Fedeial Isw enforcement agenGes, and !n response to a oourt maglstrate or admin7shative tribunaL The provlslons of criminal and civii fiaud stafutes, lnduding 18 USC 28B, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the !nlormatlon provlded. Accordtng to the Papervvork Reduction Ad of 1995, an agency may not condud or sponsor, and a person is not requlred fo respond fo, a collet�n of lnformation unless !t displays a vadd OMB control number. The valld OMB control number for thts inPormatlon collectlon Is 0580-0204. The tlme requlred to complete this lnformatron collecfion !s estimated to average 15 minutes per respanse, lnduding the time for reNewing lnshuctlons, searching exlsting data sources, gafhering and mafnfa(ning fhe dafa needea; and compleGng and reviewing the collectfon of information. RETURN THIS COMPLEfED FORp9 TO YOUR COUNTY FSA OFFlCE. On this (r) aa--"� day of (s)_� a+ in the year (t) � o I � , before me, the undersi ed a Nota Public in and for said State erso a y ppeaie� � � �, ry ,p � � M`C- �, H��:., � M�c��;.� personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) su bscri bed 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 individu::tfis1 acfe�i. �Aecut� �e instrament.