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

440 (Rev. 12/03) 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 ASL -1 Notice of Claim of Agricultural Services Lien In keeping with ORS 192.410-192.595, the information on the application is public record. Pursuant to ORS 87.242 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 : (Name of owner(s) of the cha ttels charged with this lien) MARK ONE If Individual, list last name first. 1 NAME: - Business - Individual 2 NAME: - Business - Individual MAILING ADDRESS : CITY STATE ZIPCODE C LAIMANT : NAME: MAILING ADDRESS : CITY STATE ZIPCODE PHONE NUMBER L IEN CLAIMANT ’S DEMAND (after deducting all credits and offsets) : $ THE UNDERSIGNED CLAIMS a lien upon certain chattels, including the following kinds of crops and/or described animals grown in the year upon or currently located at the following descr ibed farmland, range, ranch, orchard land: THE LIEN ALSO IS CLAIMED upon the proceeds of the sale of any or all of said crops and animals and to the unborn progeny of said animals, which are in utero on the date of the filing of this claim of lien. This lien is claimed for labor performed, materials supplied and/or s ervices provided by claimant at the request of the owner of said chattels to aid the growing or harvesting of crops and for the raising of livestock upon the land described above. The provided labor, materials and/or services consisted of The amount for which this lien is claimed is a true and bona fide existing debt as of t he date of the filing of this notice of claim of lien. The date on which payment was due claimant for said labor, supplies and services was The terms of extended payment (if any) are STATE OF OREGON , COUNTY OF I, the claimant/representative of the claimant nam ed in the forgoing notice of claim of lien, being first duly sworn, depose and say that I know the contents t hereof and that the statements and claims made therein are in all respects correct and true, as I verily believe. C LAIMANT ’S OR REPRESENTATIVE ’S SIGNATURE S UBSCRIBED AND SWORN /AFFIRMED BEFORE ME THIS DAY OF , 20 . By: Notary Public of Oregon 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.