Printed 11/9/2018Diversifiec:i Page 1 of 3 Croplnsuran<eServices~

541 Darby Cree Ste 180 Lexington, KY 40509 PRODUCTION AND YIELD REPORT

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INSURED'S NAME

M Real Estate, Inc

INSURED'S ADDRESS

211 Mixon Av,

Marianna, AR 723,0

INSURED'S TELEPHONE ~U MBER eSURED'S TAX ID NUMBER AND TYPE

(870) 295-0995 EIN: XX-XXX9288

~~cticeJJypeIT-Yield ap Area/Other Characteristics 1 '6~ J DLl)o ill "i3' . (JtJ ~

FSA FarmITract Field Nurnlor Legal Descriptions'

31D If

YIELD INDICATOR: IOpt Out Cup 0 LAND IN OTHER COUNTI [5? Record Type'

Yes 0 No 0 Note: ap;~es to all three databases on form

OTHER PERSON(S) SHAFlNG CROP

FIELD NAME

COMMENTS SECTION

REQUIRED Added Land/New 0 Field Review InSlection CroplPracticelTypelTMA

PROC NO.INAME &lOR fl. JF TREESNINES T-Yield Map I/o? J%!£U YEAR PRODUCTIO,", ACRES YIELD YA YEOPT DESC

OUT

1D9, LJo,~ 13-:: If 10 ~~lf, () lI S" J+ /I J '?.<.() ,..,,, ~ 1:;2 ·I+IIJ ./f ~L"-5 ;l (3 '?LDlLi) a~ fi J4 q1.~ d.- 0C1 fl J'; Jgl.. ~ J..Ju fl If, :J.3~, g Lq~ A 11 :~,~.o 1~<& fl}g '29>4, <b ~ 11- A

PRIOR YIELD IS1.D YIELD TOTAL / 9'1& APPROVEDfDETERMINEO YIELD / 'rif.- 0 DIVIDED BY 10 ADJUSTED YIELD RATElAVG YIELD I" Lf Multi Crot! Year ReE!:Jrting Reason

2 :

I(JC1

NSURANCE PROVIDER CGB Insurance Company

AGENCY

East Central Arkansas Insurance, Inc. - 651-1724

AGENT

Debra Busby

List Companion Policy(s):

1~:racticeITY~-Yiel~PAre~~;;raracteristics 1 U~ I a)1ol'C-e - J.., - .LinA 'i, (RJ -I

FSA FarmITract Field Number Legal Oescriptions2

3"'vi/'

YIELD INDICATOR: lOPI Out Cup 0

LAND IN OTHER COUNTIES? Record Type' Yes 0 No 0 Note: applies 10 alllhree dalabases on form

OTHER PERSON(S) SHARING CROP

FIELD NAME

COMMENTS SECTION

REQUIRED Added Land/Ne~ c::: Field Review Inspection Crop/PracticelTypelTMA

PROC NOJNAME &lOR # OF TREESNINES T-Yield Map o¥I~I J%:!f!' YEAR PRODUCTION ACRES YIELD YA YEOPT DESC

OUT

53'5./ _7t.f3b It I () 4 '1D &. (P{)7b A II ;t33. I 'i~, 7 0 A 12- 1 4.'2,fo,~ 8 / 4 ';- If 1~ 37J. .0 g l 'fl, A )4- .4Ci'K. tI-- g 3 7D A );;- :'-/. t1</. q fSOS~ A //7 ?-.7(· 'f 7h5D A II .~~-:{' g2.%' A)g

II';,

::l{lJq. ~ 112 3')) A PRIOR YIELD 'ft.33.;') YIELD TOTAL %OISll. D APPROVED/DETERMINED YIELD ~0 ~CZ DIVIDED BY Ii) ADJUSTED YIELD RATElAVG YIELD ~~ 'i) Multi Crot! Year Ret!0rting Reason 2:

1. Record Type: Refer to la£! page for applicable codes. 2. Multi Crop Year Reporting: Refer to last page tor applicable codes.

;;: Legal Description (Sectior.,. Township, Range. other land identifier (e.g ., Spanish land grants, metes and bounds, etc.}

CROP YEAR POLICY NUMBER 2018 13120-AR

STATE COUNTY

(5) Arkansas (077) Lee

J c~~ra~~~eIT-Yi e l d Map Area/Other Characteristics 1 ~V)~CiJl}

FSA FarmrTract Field Number Legal Descriptions'

310 4 I

YIELD INDICATOR: IOpt Oul Cup 0 LAND IN OTHER COUNTIES? Record Type'

Yes 0 No n Note: applies to all three databases on form

OTHER PERSON(S) SHARING CROP

FIELD NAME

COMMENTS SECTION

REQUIRED Added Land/New C Field Review InspecUon CroplPractcelTypelTMA

PROC NO JNAME &lOR # OF TREESNINES T·Yield Map LJ'7 Jo/:?lll_ YEAR PRODUCTION ACRES YIELD YA YEOPT DESC

OUT

oC! lJ,'f;)' 0 5& A )0 ?-g 1"") 3 7 A J/ '#'14.if 5'1 # 12 1,,"1) ,''6 fptf J /2-> 4.5 ~. I 5lf5 1 JCJ.. _"'1Io£. 1 5~ /'

5/3·¥' h~" .J. J/, Jqqt;-3 (p2. A 11, 1/1J?~ 3 10 - j f! /3 Iq.ll4 II

. i! PRIOR YIELD ~1 YIELD TOTAL57 ID APPROVEDIDETERMINED YIELD ,C; 7 DIVIDED BY /6 ADJUSTED YIELD RATElAVG YIELD 57 Multi Crot! Year Ret!0rting Reason 2:

___ Diversifi~ Page 2 of 3 Printed 11/9/2018 CroplnsuraneServices

PRODUCTION AND YIELD REPORT .......... ' .., .... .,J .............. ..... v ,,",v ~,, ~. ':;;1'- •• • • • • ,-~--

INSURED'S NAME

M Real Estate, Inc NSURANCE PROVIDER

CGB Insurance Company CROP YEAR

2018 POLICY NUMBER

13120-AR

INSURED'S ADDRESS f.GENCY STATE COUNTY

211 Mixon Av. Marianna, AR 72350

East Central Arkansas Insurance, Inc. - 651-1724

AGENT Debra Busby

(5) Arkansas (077) Lee

INSURED'S TELEPHONE liUMBER rNSURED'S TAX ID NUMBER AND TYPE (870) 295-0995 EIN: XX-XXX9288

list Companion Policy(s):

Multi Crop Year Repoting Reason: Enter the applicable code(s) for the reason the insured is reporting a crop year other than the most recent APH crop year. Insureds may certify production reports for crop years other than the most

recent for various reas(Os, including: A. Certification of crop years not previously certified; B. Correction; C. Replacement of temporary yield; D. Replacement of assigned yield; E . Certification by new insured; F. Certification using another oroducer's histJrv for new acreaae: G. Recertification for new actuarial offer: H. Recertification for new unit structure: or I. Other: If not aoclicable. leave blank.

Record Type(Code): A. Production Sold/Commercial Storage; B. Farm Storaged Measured by Insured; C. Pick/Daily Sales Records; D. Automated Yield Monitoring System; E. Farm-Stored Measured by Authorized Representative;

Livestock Feedino Rec:rds: G. Claim for Indemnitv: H. Aooraisal (non-loss): I. Field Harvest Records: and/or J. Other.

Non-Discrimination Statement

In accordance with Fe'ceral law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discrirnhating on the basis of race , color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, pGitical beliefs, or reprisal or retaliation for prior civil ri9hts activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).

To File a Program COrTIJlaint: If you wish 10 file a Civi Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at https://www.ascr.usda.gov/ad-3027-usda-program-discrimination-complaint-form, or at any USDA office, or C<11 (866) 632-9992 to request the form . You may also write a letter containing all of the information requested in the form . Send your completed complaint form or letter by mail to the U.S. Departmenl of Agriculture, Office of th, Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or email at program.intake@usda.gov.

Persons with Disabilitie; : Persons with disabiliti ES who require alternative means of communication for program information (e.g ., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible State or local Agency that adminislers the progran or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA Ihrough the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

Persons with disabililie" who wish to file a program complaint, please see information above on how to contact the Department by mail directly or by email.

Collection of Information and Data (Privacy Act) Statement

Agents, Loss Adjusters, and Policyholders

The following statemen:s are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a): The Risk Management Agency (RMA) is authorized by the Federal Crop Insurance Act (7 U.S.C. 1501-1524) or other Acts, and the regulations promulgatel thereunder, to solicitlhe information requested on documents established by RMA, or by approved insurance providers (AlPs), that have been approved by the Federal Crop Insurance Corporation (FCIC) , to deliver Federal crop in SJrance. The information is necessary for AlPs and RMA to operate the Federal crop insurance program, determine program eligibility, conduct statistical analysi s, and ensure program integrity. Information provided herein may t>efurnished to olher Federal, State, or local agencies, as required or permitted by law, law enforcement agencies, courts or adjudicative bodies, foreign agencies, magistrate, admin istrative tribunal , AlPs contractors and coope rators, Comprehensive Information Management System (CIMS), congressional offices, or entities under contract with RMA.

For insurance agents, certain information may also be disclosed to the public to assist interested individuals in locating agents in a particular area. Disclosure of the information requested is voluntary. However, failure to correclly report the requested information may result in the rejection of this documenl by the AlP or RMA in accordance with the Standard Reinsurance Agreement between the AlP and FCIC, Federal regulations , or RMA-approved procedures and the denial of program efgibility or benefils derived therefrom. Also, fa ilu re to provide true and correct information may result in civil suit or criminal prosecution and the assessment of penalties or pursuit of other remedies.

New Producer

o Crops(s) : ____________________________

*1 certify that I ha,,~ not produced the insured crop in the county for more than two APH crop years. *1 certify that I wa s not a member of another insured entity as a substantial beneficial interest holder, which produced the insured crop in the county for more than two APH crop years. *1 certify that any ~ubstantial beneficial interest holders for the policy in which new producer status is requested , have not produced the insured crop in the county for more than two APH crop years. *1 understand tha1any mis-certification may result in recalculation of my yield guarantees, premiums, and any applicable loss paymenls. *1 certify that to the best of my knowledge and belief all of the infomration on this form is correct. I also understand that failure to report completely and accurately may result in sanctions under my policy, including but notlimiled to voidance of the policy, and in criminal or civil penalties (18 U.S.C. §1006 and §1014; 7 U.S.C. §1506; 31 U .S .C. §3729, §3730 and any other applicable federal statutes).

t understand this form nay be reviewed or audited and that information inaccurately reported or failure to retain records to support information on this form may result in a recomputation of the approved APH yield . I certify that to the best of my knowledge and belief al of the information on this form is correct. I also understand that failure to report completely and accurately may result in sanctions under my policy, including but nollimited to voidance of the policy, and in criminal or civil penalties (18 U.S.C. § 1006 and § 1014; 7 U.S.C. §1506; 31 U.S.C. § 3729. § 3730 and any other applicable federal statutes).

INSURED'S PRINTED IIAME I INSURED'S SIGNATURE 1 DATE

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Page 3 of 3 Printed 11/9/2018Diversifie<i ___ CroplnsuraneServices

541 Darby Cre-e Ste 180 Lexington, KY 40509 PRODUCTION AND YIELD REPORT INSURED'S NAME

M Real Estate , Inc NSURANCE PROVIDER

CGB Insurance Company CROP YEAR

2018 POLICY NUMBER

13120-AR

INSURED'S ADDRESS

211 Mixon Av. Marianna , AR 723;0

INSURED'S TELEPHONE lUMBER

(870) 295-0995 CSURED'S TAX 10 NUMBER AND TYPE

EIN: XX-XXX9288

f"-GENCY

East Central Arkansas Insurance, Inc, - 651-1724 f"-GENT

Debra Busby List Companion Policy(s):

I

STATE

(5) Arkansas COUNTY

(077) Lee

J

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