UCC FINANCING STATEMENT
FOLLOW INSTRUCTIONS (front and back) CAREFULLY A. NAME & PHONE OF CONTACT AT FILER [optional] B. SEND ACKNOWLEDGMENT TO: (Name and Address)
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1. DEBTOR'S EXACT FULL LEGAL NAME - insert only one debtor name (1a or 1b) - do not abbreviate or combine names
1a. ORGANIZATION'S NAME
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THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY
OR 1b. INDIVIDUAL'S LAST NAME
1c. MAILING ADDRESS
FIRST NAME
MIDDLE NAME
SUFFIX
CITY
STATE
POSTAL CODE
COUNTRY
1d. SEE INSTRUCTIONS
ADD'L INFO RE 1e. TYPE OF ORGANIZATION ORGANIZATION DEBTOR
1f. JURISDICTION OF ORGANIZATION
1g. ORGANIZATIONAL ID #, if any NONE
2. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME - insert only one debtor name (2a or 2b) - do not abbreviate or combine names
2a. ORGANIZATION'S NAME
OR
2b. INDIVIDUAL'S LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
2c. MAILING ADDRESS
CITY
STATE
POSTAL CODE
COUNTRY
2d. SEE INSTRUCTIONS
ADD'L INFO RE ORGANIZATION DEBTOR
2e. TYPE OF ORGANIZATION
2f. JURISDICTION OF ORGANIZATION
2g. ORGANIZATIONAL ID #, if any NONE
3. SECURED PARTY'S NAME (or NAME of TOTAL ASSIGNEE of ASSIGNOR S/P) - insert only one secured party name (3a or 3b)
3a. ORGANIZATION'S NAME
OR
3b. INDIVIDUAL'S LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
3c. MAILING ADDRESS
CITY
STATE
POSTAL CODE
COUNTRY
4. This FINANCING STATEMENT covers the following collateral:
5. ALTERNATIVE DESIGNATION [if applicable]: LESSEE/LESSOR CONSIGNEE/CONSIGNOR BAILEE/BAILOR SELLER/BUYER This FINANCING STATEMENT is to be filed [for record] (or recorded) in the REAL 6. 7. Check to REQUEST SEARCH REPORT(S) on Debtor(s)
ESTATE RECORDS. Attach Addendum [if applicable] [ADDITIONAL FEE] [optional]
AG. LIEN All Debtors
NON-UCC FILING Debtor 1 Debtor 2
8. OPTIONAL FILER REFERENCE DATA
FILING OFFICE COPY UCC FINANCING STATEMENT (FORM UCC1) (REV. 05/22/02)
International Association of Commercial Administrators (IACA)