Free ra9_ucc_N1.p65 - Idaho

STATE OF IDAHO - COUNTY MEDICAL - FORM N1
Mail to: Secretary of State UCC Division 450 N Jefferson 700 W 4th PO Box 83720 Boise ID 83720-0080 Telephone: 208-334-3191 Fax: 208-334-2847
This block for Filing Office use only.

Instructions: 1. Please type and sign this form in black. 2. File only the original. Make copies for your file. The original will be returned as your acknowledgment. 3. Enter only one debtor's name or assumed name per debtor block exactly as it is to be indexed. If more than four names, use an attached sheet. 4. When the obligation has been satisfied, complete the Termination Statement and return the original to the filing officer.

Name or business name of each debtor against whom the lien is claimed, and the address of each.

1 2 3 4

Organization or Indiv. Last Name

First Name

Middle Name State Zip

Suffix

Address

City

Organization or Indiv. Last Name

First Name

Middle Name

Suffix

Address Organization or Indiv. Last Name

City

State Middle Name

Zip

First Name City

Suffix Zip

Address

State

Organization or Indiv. Last Name

First Name

Middle Name

Suffix

Address

City

State

Zip

Secured Party Name and Address
Organization or Indiv. Last Name Address First Name City Middle Name State Zip

Assignee Name and Address
Organization or Indiv. Last Name First Name Middle Name

Address

City

State

Zip

Acknowledgment Name and Address, if not Secured Party
Organization or Indiv. Last Name First Name City Middle Name State Zip

Address

This financing statement covers the following types or items of property:

Signature of Secured Party:

TERMINATION STATEMENT The Secured Party no longer claims a security interest under the financing statement.

Signature of Secured Party / Assignee of Record
Rev. 07/2001

Date