Form Ucc-5 - Statement Of Claim - 2011

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( UCC- 5 )

STATEMENT OF CLAIM

The filing of this statement of claim does not affect the effectiveness

of an initial financing statement or other filed record.

FOLLOW INSTRUCTIONS (front and back) CAREFULLY

A. NAME & PHONE OF PERSON FILING THIS STATEMENT [optional]

B. SEND ACKNOWLEDGMENT TO: (Name and Address)

THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY

RECORD

STATEMENT OF CLAIM

Identification of the

to which this

relates.

1a. INITIAL FINANCING STATEMENT FILE NUMBER

1b. RECORD INFORMATION TO WHICH THIS STATEMENT OF CLAIM RELATES

2a.

RECORD is inaccurate.

Provide the basis for the belief of the person identified in item 4 that the RECORD identified in item 1 is inaccurate and indicate the manner in which the person believes the RECORD

should be amended to cure the inaccuracy.

2b.

RECORD was wrongfully filed.

Provide the basis for the belief of the person identified in item 4 that the RECORD identified in item 1 was wrongfully filed.

If this STATEMENT OF CLAIM relates to a RECORD filed [or recorded] in a filing office described in Section 9-501(a)(1) and this STATEMENT OF CLAIM is filed in such a filing office,

provide the date [and time] on which the INITIAL FINANCING STATEMENT identified in item 1a above was filed [or recorded].

3a. DATE

3b. TIME

4. NAME

PERSON AUTHORIZING THE FILING OF THIS STATEMENT OF CLAIM —

The RECORD identified in item 1 must be indexed under this name.

4a. ORGANIZATION'S NAME

4b. INDIVIDUAL'S LAST NAME

FIRST NAME

MIDDLE NAME

SUFFIX

SOUTH CAROLINA SECRETARY OF STATE'S OFFICE, 1205 Pendleton Street Suite 525 Columbia, SC 29201