Form Ucc5 - Statement Of Claim With Instructions

Form Ucc5 - Statement Of Claim With Instructions - 2009

The filing of this statement

of claim does not affect

the effectiveness of an

initial financing statement

or other filed record.

STATEMENT OF CLAIM

FOLLOW INSTRUCTIONS (front and back) CAREFULLY

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

B. SEND ACKNOWLEDGMENT TO: (Name and Address)

Reset

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].

3b. TIME

3a. DATE

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

MIDDLE NAME

4b. INDIVIDUAL'S LAST NAME

FIRST NAME

SUFFIX

International Association of Commercial Administrators (IACA)