Form Ucc5 - Statement Of Claim With Instructions

Instructions for Statement of Claim (Form UCC5)

Please type or laser-print this form. Be sure it is completely legible. Read all Instructions, especially Instructions 1a and 1b; correct identification of the

initial Record to which this Statement of Claim relates is crucial. Follow Instructions completely.

Fill in form very carefully. If you have questions, consult your attorney. Filing office cannot give legal advice.

Do not insert anything in the open space in the upper portion of this form; it is reserved for filing office use.

When properly completed, send Filing Office Copy to filing office. Always detach Debtor and Secured Party Copies.

ITEM INSTRUCTIONS

A. To assist filing offices that might wish to communicate with filer, filer may provide information in item A. This item is optional.

B. Complete item B if you want an acknowledgment sent to you. If filing in a filing office that returns an acknowledgment copy furnished by filer, present

simultaneously with this form a carbon or other copy of this form for use as an acknowledgment copy.

General — You must always complete items 1 and 4 and either 2a or 2b. You may also be required to complete item 3.

1a. File number: Enter file number of initial financing statement to which the Record that is the object of this Statement of Claim relates. Enter only

one file number.

1b. Enter record information to which this Statement of Claim relates. Indicate the type of Record to which this Statement of Claim relates (e.g., Financing

Statement or Amendment) or you may also insert additional information that you believe will assist in identifying the Record (e.g., the Record file

number or the filing date of the Record).

2a. If this Statement of Claim is filed based on the filer's belief that the Record identified in item 1 is inaccurate, check box 2a, provide the basis for that

belief, and indicate the manner in which the Record should be amended to cure the inaccuracy.

2b. If this Statement of Claim is filed based on the filer's belief that the Record identified in item 1 was wrongfully filed, check box 2b and provide the

basis for that belief.

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].

Always enter name of the person who authorized the filing of this Statement of Claim. This name must be the same as the name under which the

Record is indexed.