Fill and Sign the Correction Statement Online Form

STATE OF FLORIDA UNIFORM COMMERCIAL CODE FINANCING STATEMENT INFORMATION FORM A. NAME & PHONE OF PERSON FILING THIS STATEMENT [optional] B. Email Address C. SEND ACKNOWLEDGEMENT TO: (Name and Address) Name Address Address City/State/Zip THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 1. INITIAL FINANCING STATEMENT FILE # This space is not available 2. CURRENT RECORD INFORMATION – DEBTOR NAME – INSERT ONLY ONE DEBTOR NAME (2a OR 2b) 2a. ORGANIZATION’S NAME 2b. INDIVIDUAL’S SURNAME FIRST PERSONAL NAME ADDITIONAL NAME(S)/INITIALS(S) SUFFIX 3. CURRENT RECORD INFORMATION – SECURED PARTY NAME – INSERT ONLY ONE SECURED PARTY NAME (3a OR 3b) 3a. ORGANIZATION’S NAME 3b. INDIVIDUAL’S SURNAME FIRST PERSONAL NAME ADDITIONAL NAME(S)/INITIALS(S) SUFFIX 4a. RECORD is inaccurate Provide the basis for the belief of the person identified in item 6 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. 4b. RECORD was wrongfully filed Provide the basis for the belief of the person identified in item 6 that the RECORD identified in item 1 was wrongfully filed. 4c. RECORD FILED BY PERSON NOT ENTITLED TO DO SO Provide the basis for the belief by the Secured Party of Record that the person that filed the RECORD identified in item 1 was not entitled to do so under UCC Section 9-509 5. If this INFORMATION STATEMENT relates to a RECORD filed [or recorded] in a filing office described in s. 679.5011 F.S. and this INFORMATION STATEMENT is filed in uch ຤ filin ffhee rofiide h e d຤he a຤n d hiee fn h ih h e NINnNLN INILIINIi TnLnMIMIn iden hified in ihee 1b ຤bfie h຤u filed afo oehfoded . 5a. DATE 5b. TIME 6. NAME OF PERSON AUTHORIZING THE FILING OF THIS INFORMATION STATEMENT – the RECORD identified in item 1 must be indexed under this name Or 6a. ORGANIZATION’S NAME 6b. INDIVIDUAL’S SURNAME FIRST PERSONAL NAME ADDITIONAL NAME(S)/INITIALS(S) SUFFIX STANDARD FORM – FORM UCC-5 (REVISED 06/2013) Filing Office Copy Approved by the Secretary of State, State of Florida