Hospital Lien Filing Form - Colorado Secretary Of State
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1Mail to: Secretary of State
For office use only
054
UCC Section
1560 Broadway, Suite 200
Please include a typed
Denver, CO 80202
self-addressed envelope
(303) 894-2251
Fax (303) 894-2242
MUST BE TYPED
FILING FEE: $ 16.00 per Injured Party
MUST SUBMIT TWO COPIES
HOSPITAL LIEN FILING FORM
You must check one of the following boxes that describes the type of document you are filing:
*
Original Hospital Lien
*
Amendment to Original Hospital Lien
*
Termination of Original Hospital Lien
If you check the "Amendment" or "Termination" box, you MUST include the original filing number
on file with the Secretary of State on the following line:
Original Filing Number
INJURED PERSON/
RESPONSIBLE PARTY
DATE OF INJURY
/
/
ADDRESS
Street
Apt. #
City
State
ZIP
SSN/FED Tax ID
PERSON ALLEGEDLY
LIABLE FOR INJURIES
HOSPITAL
ADDRESS
Street
Apt. #
City
State
ZIP
SIGNATURE OF FILER
DATE
/
/
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Parent category: Legal