§ 12A-1-9-521 — Uniform form of written financing statement and

amendment. UNIFORM FORM OF WRITTEN FINANCING STATEMENT AND AMENDMENT (a) 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 subsection (b) of Section 1-9-516 of this title: UCC FINANCING STATEMENT FOLLOW INSTRUCTIONS A. NAME AND PHONE OF CONTACT AT FILER (optional) _____________________________________________ B. E-MAIL CONTACT AT FILER (optional) C. SEND ACKNOWLEDGMENT TO: (Name and Address) ________________________________________ ________________________________________ THE ABOVE SPACE IS FOR ________________________________________ FILING OFFICE USE ONLY 1. DEBTOR'S NAME – provide only one Debtor name (1a or 1b) – (use exact, full name; do not omit, modify, or abbreviate any word in the Debtor's name) 1a. ORGANIZATION'S NAME _______________________________________________________________ OR 1b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS DEBTOR SUFFIX ________________________________________ _______________ 1c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY _______________________________________________________________ 2. DEBTOR'S NAME – provide only one Debtor name (2a or 2b)(use exact, full name; do not omit, modify, or abbreviate any word in the Debtor's name) 2a. ORGANIZATION'S NAME _______________________________________________________________ OR 2b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS DEBTOR SUFFIX ________________________________________ _______________ 2c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY _______________________________________________________________ 3. SECURED PARTY'S NAME (or NAME of ASSIGNEE of ASSIGNOR SECURED PARTY) – provide only one Secured Party name (3a or 3b) 3a. ORGANIZATION'S NAME ______________________________________________________________ OR 3b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) SUFFIX ________________________________________ __________________ 3c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY _______________________________________________________________ 4. COLLATERAL: This financing statement covers the following collateral: _______________________________________________________________ 5. Check only if applicable and check only one box: Collateral is: [ ] held in a Trust (see instructions) [ ] being administered by a Decedent's Personal Representative. 6a. Check only if applicable and check only one box: [ ] Public-Finance Transaction [ ] Manufactured-Home Transaction [ ] A Debtor is a Transmitting Utility 6b. Check only if applicable and check only one box: [ ] Agricultural Lien [ ] Non-UCC Filing 7. ALTERNATIVE DESIGNATION (if applicable): [ ] Lessee/Lessor [ ] Consignee/Consignor [ ] Seller/Buyer [ ] Bailee/Bailor [ ] Licensee/Licensor 8. OPTIONAL FILER REFERENCE DATA _______________________________________________________________ UCC FINANCING STATEMENT (Form UCCI) UCC FINANCING STATEMENT ADDENDUM FOLLOW INSTRUCTIONS 9. NAME OF FIRST DEBTOR (same as item 1a or 1b on Financing Statement) 9a. ORGANIZATION'S NAME _______________________________________________________________ OR 9b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _________________________ __________________________ ADDITIONAL NAME(S)/INITIAL(S) SUFFIX ________________________________________ _______ ________________________________________ THE ABOVE SPACE IS FOR ________________________________________ FILING OFFICE USE ONLY 10. ADDITIONAL DEBTOR'S NAME – provide only one Debtor name (10a or 10b) - (use exact, full name; do not omit, modify, or abbreviate any word in the Debtor's name) 10a. ORGANIZATION'S NAME _______________________________________________________________ OR 10b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME ___________________________ ___________________________ ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS DEBTOR SUFFIX ________________________________________ _______________ 10c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY _______________________________________________________________ 11. [ ] ADDITIONAL SECURED PARTY'S NAME or [ ] ASSIGNOR SECURED PARTY'S NAME – provide only one name (11a or 11b) 11a. ORGANIZATION'S NAME _______________________________________________________________ OR 11b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) SUFFIX _______________________________________________ _______ 11c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY _______________________________________________________________ 12. ADDITIONAL SPACE FOR ITEM 4 (Collateral) ______________________________________________________________ 13. This FINANCING STATEMENT is to be filed (for record) (or recorded) in the REAL ESTATE RECORDS (if applicable) 14. This FINANCING STATEMENT: [ ] covers timber to be cut [ ] covers as-extracted collateral [ ] is filed as a fixture filing 15. Name and address of a RECORD OWNER of the real estate described in item 16 (if Debtor does not have record interest): _______________________________________________________________ 16. Description of real estate: _______________________________________________________________ 17. MISCELLANEOUS: ______________________________________________________________ (b) A filing office that accepts written records for filing may not refuse to accept a written financing statement amendment in the following form, except for a reason set forth in subsection (b) of Section 1-9-516 of this title: UCC FINANCING STATEMENT AMENDMENT FOLLOW INSTRUCTIONS A. NAME AND PHONE OF CONTACT AT FILER (optional) _______________________________________________________________ B. E-MAIL CONTACT AT FILER (optional) _______________________________________________________________ C. SEND ACKNOWLEDGMENT TO: (Name and Address) _______________________________________ _______________________________________ THE ABOVE SPACE IS FOR _______________________________________ FILING OFFICE USE ONLY 1a. INITIAL FINANCING STATEMENT FILE NUMBER _______________________________________________________________ 1b. [ ] This FINANCING STATEMENT AMENDMENT is to be filed (for record) (or recorded) in the REAL ESTATE RECORDS. Filer: attach Amendment Addendum (Form UCC3Ad) and provide Debtor's name in item 13. 2. [ ] TERMINATION: Effectiveness of the Financing Statement identified above is terminated with respect to security interest(s) of Secured Party authorizing this Termination Statement. 3. [ ] ASSIGNMENT (full or partial): Provide name of Assignee in item 7a or 7b, and address of Assignee in item 7c and name of Assignor in item 9. For partial assignment, complete items 7 and 9 and also indicate affected collateral in item 8. 4. [ ] CONTINUATION: Effectiveness of the Financing Statement identified above with respect to security interest(s) of Secured Party authorizing this Continuation Statement is continued for the additional period provided by applicable law. 5. [ ] PARTY INFORMATION CHANGE: Check one of these two boxes: This Change affects [ ] Debtor or [ ] Secured Party of record. AND Check one of these three boxes to: [ ] CHANGE name and/or address: Complete item 6a or 6b, and item 7a or 7b and item 7c. [ ] ADD name: Complete item 7a or 7b, and item 7c. [ ] DELETE name: Give record name to be deleted in item 6a or 6b. 6. CURRENT RECORD INFORMATION: Complete for Party Information Change – provide only one name (6a or 6b) (use exact, full name; do not omit, modify, or abbreviate any word in the Debtor's name). 6a. ORGANIZATION'S NAME _______________________________________________________________ OR 6b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) SUFFIX ___________________________________ __________________ 7. CHANGED OR ADDED INFORMATION: Complete for Assignment or Party Information Change – provide only one name (7a or 7b) (use exact full name; do not omit, modify, or abbreviate any word in the Debtor's name). 7a. ORGANIZATION'S NAME _______________________________________________________________ OR 7b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS DEBTOR SUFFIX _______________________________________________________________ 7c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY _______________________________________________________________ 8. [ ] COLLATERAL CHANGE: _______________________________________________________________ Also check one of these four boxes: [ ] ADD collateral [ ] DELETE collateral [ ] RESTATE covered collateral [ ] ASSIGN collateral Indicate collateral: _______________________________________________________________ 9. NAME OF SECURED PARTY OF RECORD AUTHORIZING THIS AMENDMENT - provide only one name (9a or 9b) (name of Assignor, if this is an Assignment). If this is an Amendment authorized by a DEBTOR, check here [ ] and provide name of authorizing Debtor. 9a. ORGANIZATION'S NAME _______________________________________________________________ OR 9b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) SUFFIX ___________________________________ _____________ 10. OPTIONAL FILE REFERENCE DATA _______________________________________________________________ UCC FINANCING STATEMENT AMENDMENT (FORM UCC3) UCC FINANCING STATEMENT AMENDMENT ADDENDUM FOLLOW INSTRUCTIONS 11. INITIAL FINANCING STATEMENT FILE NUMBER (same as item 1a on Amendment form). _______________________________________________________________ 12. NAME OF PARTY AUTHORIZING THIS AMENDMENT (same as item 9 on Amendment form). 12a. ORGANIZATION'S NAME _______________________________________________________________ OR 12b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) SUFFIX ________________________________________ _____________ ________________________________________ THE ABOVE SPACE IS FOR ________________________________________ FILING OFFICE USE ONLY 13. Name of DEBTOR on related financing statement (Name of a current Debtor of record required for indexing purposes only in some filing offices – see Instruction for item 13 – insert only one Debtor name (13a or 13b) (use exact, full name; do not omit, modify, or abbreviate any word in the Debtor's name). 13a. ORGANIZATION'S NAME. _______________________________________________________________ OR 13b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME _______________________________________________________________ ADDITIONAL NAME(S)/INITIAL(S) SUFFIX _____________________________________ _____________ 14. ADDITIONAL SPACE FOR ITEM 8 (Collateral) _____________________________________________________________ 15. This FINANCING STATEMENT AMENDMENT: [ ] covers timber to be cut [ ] covers as-extracted collateral [ ] is filed as a fixture filing. 16. Name and address of a RECORD OWNER of real estate described in item 17 (if Debtor does not have a record interest): ______________________________________________________________ 17. Description of real estate: ______________________________________________________________ 18. MISCELLANEOUS: ______________________________________________________________ UCC FINANCING STATEMENT AMENDMENT ADDENDUM (Form UCC3Ad) (c) A form that a filing office may not refuse to accept under subsection (a) or (b) of this section must conform to the format prescribed for the form by the National Conference of Commissioners on Uniform State Laws.

Legislative History

Added by Laws 2000, c. 371, § 99, eff. July 1, 2001. Amended by Laws 2015, c. 374, § 15, eff. Nov. 1, 2015.