Fill and Sign the Asl 1 Notice of Claim of Agricultural Services Lien Form

430 (Rev. 8/02) Secretary of State Corporation Division - UCC 255 Capitol St. NE, Ste. 151 Salem, OR 97310-1327 Phone: (503) 986-2200 Fax: (503) 373-1166 FilingInOregon.com APL -1 Notice of Agricultural Produce Lien In keeping with ORS 192.410-192.595, the information on the application is public record. Pursuant to ORS 87.710 We must release this information to all parti es upon request and it may be posted on our website. Please Type or Print Legibly in Black Ink. Attach Additional Sheet if Necessary. DEBTOR Mark One If Individual, list last name first. PURCHASER : NAME 1 - Business - Individual N AME 2 - Business - Individual ADDRESS CITY STATE ZIPCODE PRODUCER : NAME ADDRESS CITY STATE ZIPCODE S TATEMENT AMOUNT OF PRODUCER ’S DEMAND (after Deducting All Credits and Offsets) : $ DESCRIPTION OF PRODUCE DELIVERED OR TRANSFERRED BY: D ATE PAYMENT ORIGINALLY DUE : I ( WE ) swear/affirm that the amount claimed on th is Notice is a true and bona fide existing debt a s of the date of this filing. S TATE OF C LAIMANT SIGNATURE C OUNTY OF D ATE S UBSCRIBED TO AND SWORN /AFFIRMED BEFORE ME THIS DAY OF , 20 , by Notary Public of Oregon My commission expires: FEES RETURN TO (Please Type or Print within the box): Required Processing Fee - $10 Processing Fees are nonrefundable. Please make check payable to “Corporation Division.” NOTE: Fees may be paid with VISA or MasterCa rd. The card number and expiration date should be submitted on a separat e sheet for your protection.