Form Ucc-11 - Information Request Form - 2003

UCC-11

Submit UCC11 Form

STATE OF SOUTH CAROLINA FILING FEES:

$ 5.00 - Each filing

$ 2.00 - Additional for additional Debtors (i.e., DBA)

$ 2.00 - Copies (First Page)

$ 2.00 - Certification (Per Copy)

$ 5.00 - Fax Fee: Incoming (Per Search)

INFORMATION REQUEST

$ 1.00 - Copies (Additional Page)

FOLLOW INSTRUCTIONS CAREFULLY

$10.00 - Fax Fee: Outgoing (Per Search)

A. NAME & PHONE OF CONTACT [optional]

FILING OFFICE ACCT #

$ 1.00 - Additional Fax Fee: Outgoing (Per page)

$ 5.00 - e-Search Fee: Incoming (Per Search)

B. RETURN TO: (Name and Address)

THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY

DEBTOR

1.

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

INFORMATION OPTIONS

2.

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

CERTIFIED (Optional)

ALL

UNLAPSED

Select one of the following two options:

(Check this box to request a response that is complete, including filings that have lapsed.)

2b. COPY REQUEST

CERTIFIED (Optional)

ALL

UNLAPSED

Select one of the following two options:

2c. SPECIFIED COPIES ONLY

CERTIFIED (Optional)

Record Number

Date Record Filed

Type of Record and Additional Identifying Information

(if required)

( if required)

ADDITIONAL SERVICES:

3.

4. DELIVERY INSTRUCTIONS: (request will be completed and mailed to the address shown in item B unless otherwise instructed here);

4a. [ ] Pick Up

4b. [ ] 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.)

The undersigned filing office hereby certifies that the above listing is a record of all presently effective financing statements and statements of assignment which name the above debtor,

and which are on file in my office as of

, 20

at

AM/PM

FILING OFFICE COPY (1) —

SC SECRETARY OF STATE'S OFFICE, P.O. BOX 11350, COLUMBIA, SC 29211

(5/14/2003)