Section 7-9A-521 Uniform form of written financing statement and amendment.

Section 7-9A-521

Uniform form of written financing statement and amendment.

(a) Initial financing statement form. A filing office that accepts written records may not refuse to accept a written initial financing statement in the following form and format except for a reason set forth in Section 7-9A-516(b):

UCC FINANCING STATEMENT

FOLLOW INSTRUCTIONS (front and back) CAREFULLY

A. NAME & PHONE OF CONTACT AT FILER (optional) ___________

B. SEND ACKNOWLEDGMENT TO: ___________ (Name and Address)

THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY

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 ___________

or

1b. INDIVIDUAL'S LAST NAME _________

FIRST NAME ___________

MIDDLE NAME _________

SUFFIX _____

1c. MAILING ADDRESS ____________________

CITY _______________

STATE __

POSTAL CODE _______

COUNTRY ___________

1d. TAX ID # SSN OR EIN ____________

ADD'L INFO RE ORGANIZATION DEBTOR ____________

1e. TYPE OF ORGANIZATION ___________

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. TAX ID # SSN OR EIN ____________

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 or 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 ___________

AG. LIEN ___________

NON-UCC FILING ___________

6. This FINANCING STATEMENT is to be filed (for record) (or recorded) in the REAL ESTATE RECORDS. Attach Addendum (if applicable)

7. Check to REQUEST SEARCH REPORT(S) on Debtor(s) ADDITIONAL FEE (optional)

_____ All Debtors

_____ Debtor 1

_____ Debtor 2

8. OPTIONAL FILER REFERENCE DATA

9. NAME OF FIRST DEBTOR (1a or 1b) ON RELATED FINANCING STATEMENT

9a. ORGANIZATION'S NAME ________________

or

9b. INDIVIDUAL'S LAST NAME ______________

FIRST NAME ___________

MIDDLE NAME, SUFFIX ____________

10. MISCELLANEOUS:

____________________

11. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME - Insert only one name (11a or 11b) - do not abbreviate or combine names

11a. ORGANIZATION'S NAME _______________

or

11b. INDIVIDUAL'S LAST NAME _____________

FIRST NAME ___________

MIDDLE NAME _________

SUFFIX _____

11c. MAILING ADDRESS ____________________

CITY _______________

STATE ___

POSTAL CODE _______

COUNTRY ___________

11d. TAX ID # SSN OR EIN ____________

ADD'L INFO RE ORGANIZATION DEBTOR ____________

11e. TYPE OF ORGANIZATION ___________

11f. JURISDICTION OF ORGANIZATION ___________

11g. ORGANIZATIONAL ID #, if any _______ NONE ___

12. ADDITIONAL SECURED PARTY'S

or

ASSIGNOR S/P'S NAME - Insert only one name (12a or 12b)

12a. ORGANIZATION'S NAME _______________

or

12b. INDIVIDUAL'S LAST NAME _____________

FIRST NAME ___________

MIDDLE NAME ________

SUFFIX _____

12c. MAILING ADDRESS ____________________

CITY ____________

STATE ___

POSTAL CODE _______

COUNTRY ___________

13. This FINANCING STATEMENT covers ____ timber to be cut or ____ as extracted collateral, or be filed as a ____ future filing.

14. Description of real estate

____________________

____________________

15. Name and address of a RECORD OWNER of above described real estate (if Debtor does not have a record interest):

____________________

16. Additional collateral description:

____________________

17. Check only if applicable and check only one box.

Debtor is a _____ Trust or _____ Trustee acting with respect to property held in trust or _____ Decedent's Estate

18. Check only if applicable and check only one box.

______ Debtor is a TRANSMITTING UTILITY

______ Filed in connection with a Manufactured Home Transaction-effective 30 years

______ Filed in connection with a Public Finance Transaction-effective 30 years

(b) Amendment form. A filing office that accepts written records may not refuse to accept a written record in the following form and format except for a reason set forth in Section 7-9A-516(b):

UCC FINANCING STATEMENT AMENDMENT

FOLLOW INSTRUCTIONS (front and back) CAREFULLY

A. NAME & PHONE OF CONTACT AT FILER ___________ (optional)

B. SEND ACKNOWLEDGMENT TO: ___________ (Name and Address)

1a. INITIAL FINANCING STATEMENT FILE #

1b. This FINANCING STATEMENT AMENDMENT is to be filed (for record) (or recorded) in the REAL ESTATE RECORDS.

2. _____ TERMINATION: Effectiveness of the Financing Statement identified above is terminated with respect to security interest(s) of the Secured Party authorizing this Termination Statement.

3. _____ CONTINUATION: Effectiveness of the Financing Statement identified above with respect to security interest(s) of the Secured Party authorizing this Continuation Statement is continued for the additional period provided by applicable law.

4. _____ ASSIGNMENT (full or partial): Give name of consignee in box 7a or 7b and address of consignee in item 7c, and also give name of assignor in Item 9.

5. AMENDMENT (PARTY INFORMATION): This Amendment affects _____ Debtor or _____ Secured Party of record. Check only one of these two boxes.

Also check one of the following three boxes and provide appropriate information in items 6 and/or 7.

_____ CHANGE name and/or address: Give current record name in Item 6a or 6b; also give new name (if name change) in Items 7a or 7b and/or new address (if address change) in Item 7c.

_____ DELETE name. Give record name to be deleted in Item 6a or 6b.

_____ ADD name. Complete Item 7a or 7b, and also Item 7c; also complete Items 7d-7g (if applicable).

6. CURRENT RECORD INFORMATION

6a. ORGANIZATION'S NAME _______________

or

6b. INDIVIDUAL'S LAST NAME _____________

FIRST NAME ___________

MIDDLE NAME _________

SUFFIX _____

7. CHANGED (NEW) OR ADDED INFORMATION:

7a. ORGANIZATION'S NAME _______________

or

7b. INDIVIDUAL'S LAST NAME _____________

FIRST NAME ___________

MIDDLE NAME _________

SUFFIX _____

7c. MAILING ADDRESS ____________________

CITY _______________

STATE ___

POSTAL CODE _______

COUNTRY ___________

7d. TAX ID # SSN OR EIN ____________

ADD'L INFO RE ORGANIZATION DEBTOR ____________

7e. TYPE OF ORGANIZATION ___________

7f. JURISDICTION OF ORGANIZATION ___________

7g. ORGANIZATIONAL ID #, if any ________ NONE ____

8. AMENDMENT (COLLATERAL CHANGE): Check only one box.

Describe collateral _____ deleted or _____ added, or give entire _____ restated collateral description, or describe collateral ______ assigned.

____________________

____________________

9. NAME OF SECURED PARTY OF RECORD AUTHORIZING THIS AMENDMENT (name of assignor, if this is an Assignment). If this is an Amendment authorized by a Debtor which adds collateral or adds the authorizing Debtor, or if this is a Termination authorized by a Debtor, check here _____ and enter name of DEBTOR authorizing this Amendment.

9a. ORGANIZATION'S NAME _______________

or

9b. INDIVIDUAL'S LAST NAME _____________

FIRST NAME ___________

MIDDLE NAME _________

SUFFIX _____

10. OPTIONAL FILER REFERENCE DATA

____________________

11. INITIAL FINANCING STATEMENT FILE # (same as Item 1a on Amendment form) __________________

12. NAME OF PARTY AUTHORIZING THIS AMENDMENT (same as Item 8 on Amendment form)

12a. ORGANIZATION'S NAME

or

12b. INDIVIDUAL'S LAST NAME _____________

FIRST NAME ___________

MIDDLE NAME, SUFFIX __________________

13. Use this space for additional information

____________________

____________________

(Act 2001-481, p. 647, §1.)