INFORMATION REQUEST
FOLLOW INSTRUCTIONS (front and back) CAREFULLY
A. NAME & PHONE OF CONTACT [optional] B. RETURN TO: (Name and Address) FILING OFFICE ACCT #
THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 1. DEBTOR NAME to be searched - insert only one debtor name (1a or 1b) - do not abbreviate or combine names
1a. ORGANIZATION'S NAME
OR
1b. INDIVIDUAL'S LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
2. INFORMATION OPTIONS relating to UCC filings and other notices on file in the filing office that include as a Debtor name the name identified in item 1: 2a. SEARCH RESPONSE 2b. COPY REQUEST 2c. SPECIFIED COPIES ONLY CERTIFIED (Optional) Select one of the following two options: Select one of the following two options:
ALL (Check this box to request a response that is complete, including filings that have lapsed.) ALL
CERTIFIED (Optional)
UNLAPSED
CERTIFIED (Optional)
UNLAPSED
Record Number
Date Record Filed ( if required) Type of Record and Additional Identifying Information (if required)
3. ADDITIONAL SERVICES:
4. DELIVERY INSTRUCTIONS (request will be completed and mailed to the address shown in item B unless otherwise instructed here): 4a. 4b. Pick Up Other
Specify desired method here (if available from this office); provide delivery information (e.g., delivery service's name, addressee's account # with delivery service, addressee's phone #, etc.)
FILING OFFICE COPY (1) NATIONAL INFORMATION REQUEST (FORM UCC11) (REV. 05/09/01)