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CCC-297 (OS-15-04) �0110�931 page2of2 IN WITNESS�EREOF, the undersigned parties hereto have executed this instrument this (h) �� day of (i) 1,��u��'� , G) °�° (Year). if a corporation: �� : �� BANK OF DONIPHAN (Mortgagee) B3' e ��st�e/ (1) Dul} A111I20Yl O�cer �,G� �2C.F� �he (m) Title CORPORATE SEAL "Mortgagee" includes holder of any type of real estate lien. *Delete "Mortgagee" or "Owner." (p) STATE OF a� (c� COUNTY OF �7�� } ss. ACKNOWLEDGMENT: On this (r) �a'7/�/ day of (s) in the vear (t1 �O / / , me, the undersigned, a Notary Public in and for said State, personally appeared ( /�lJlll,Gyt � '��• , personally known to me or proved to me on the basis of satisfactory evidence to hP the �ndividual{s; �khose name;s) ' (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(sl acted. execute the instrument. .......�r...... �� AL) Qomm. 19, 2dt� (v) No Public My commission expires (w) 9��q�� (M -DD-YYY� The foUowing stetement 7s made !n accordance wifh fhe Privacy Ad o/ 1974 (5 USC 552e) and the Papeiwork Reducfion Ad of 1995, as emended. The authaRy for requestic the lollowing informaffon is 7 CFR Part 1436 and the Commodity Credit Corporatton CharterAd, 5 USC 714 et. seq. The informadon wiil be used to detarmine el'rc�ibUity lor CCC finencing !or /erm, storage and drying equipment Fumishing the requested informaUon Is vo/urttary, however, wifhout it CCC finandn8 under fhe progism cannof be provlded. FaUure to /umish the requested lnlormaBon will result in denia! of CCC Rnancing under this progrem. Thls lnformaBon may be provided to other agenaes, IRS, Departmem of JusN�, or other SYate and Federal law enlo�ment agendes, and in response to a wurt maglsbate or adminlsbedve tribunaL The provisions of crimine/ and aW /iaud stetutes, lnduding 18 USC 286, 287, 371, 841, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicabfe to the infoimaBon provrded. According to the Papervvork ReducBon Act o/1995, an egency may not conduct or s,00nsor, and a person is not required to raspond to, a collectfon o/infamation unless if drsplays a velld OMB wrrdol number. The valld OMB �nhol numberla this lnlormaBon crollecdon is 0560-0204. The dme required to complete this informaBon collectron is esdmated to average 1 b minutes per responsre, induding the Bme for reviewing instructions, searching earisting data sources, gathering and mainteining the data needed, and comp/eting and reviewing the colledion of information. RETURN TH/S COIV�PLETED FORM TO YOUR COUNTY FSA OFFICE.