Fill and Sign the Information Statement Form Ucc5 PDF

FILING OFFICE COPY — INFORMATION STATEMENT (Form UCC5) (Rev. 07/19/12) THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY INFORMATION STATEMENTFOLLOW INSTRUCTIONS A. NAME & PHONE OF CONTACT AT FILER (optional) 1. Identification of the RECORD to which this INFORMATION STATEMENT relates OR 5b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME 1a. INITIAL FINANCING STATEMENT FILE NUMBER ADDITIONAL NAME(S)/INITIAL(S) SUFFIX 5a. ORGANIZATION'S NAME 5. NAME of PERSON filing this INFORMATION STATEMENT 1b. RECORD INFORMATION TO WHICH THIS INFORMATION STATEMENT RELATES 2.Check one of these three boxes to indicate the claim made by this INFORMATION STATEMENT 3. Basis for claim of box checked in item 2 4.If this INFORMATION STATEMENT relates to a RECORD filed [or recorded] in a filing office described in Section 9-501(a)(1) and this INFORMATION STATEMENT 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] 4a. DATE 4b. TIME CAUTION: This is not an amendment. C. SEND ACKNOWLEDGMENT TO: (Name and Address) B. E-MAIL CONTACT AT FILER (optional) RECORD IS INACCURATE. Enter in item 3 the basis for the belief by the Debtor of Record identified in item 5 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 2a. RECORD WAS WRONGFULLY FILED. Enter in item 3 the basis for the belief by the Debtor of Record identified in item 5 that the RECORD identified in item 1 was wrongfully filed 2b. RECORD FILED BY PERSON NOT ENTITLED TO DO SO. Enter in item 3 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 2c. Instructions for Information Statement (Form UCC5) Please type or laser-print this form. Be sure it is completely legible. Read and follow all Instructions, especially Instructions 1a and 1b; correct identification of the initial record to which this Information Statement relates is crucial. Fill in form very carefully; mistakes may have important legal consequences. If you have questions, consult your attorney. The filing office cannot give legal advice. Send completed form and any attachments to the filing office, with the required fee. Note:A person may file an Information Statement with respect to a record indexed under that person's name if the person believes the record was inaccurate or wrongfully filed, or a person may file an Information Statement with respect to a record if the person is a Secured Party of Record with respect to the financing statement to which the record relates and believes that the person that filed the record was not entitled to do so. ITEM INSTRUCTIONS A and B. To assist filing offices that might wish to communicate with filer, filer may provide information in item A and item B. These items are optional. C. Complete item C if filer desires an acknowledgment sent to them. If filing in a filing office that returns an acknowledgment copy furnished by filer, present simultaneously with this form the Acknowledgment Copy or a carbon or other copy of this form for use as an acknowledgment copy. Always complete items 1 and 5 and either 2a or 2b or 2c. Always complete item 3 with the basis for the box marked in item 2. You may also be requiredto complete item 4. 1a.File number: Enter file number of initial financing statement to which the record that is the object of this Information Statement relates. Enter only one file number. 1b. Enter record information to which this Information Statement relates. Indicate the type of record to which this Information Statement 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.Record is inaccurate. If this Information Statement is filed based upon the belief of the Debtor of Record that the record identified in item 1 is inaccurate, check box in item 2a, provide the basis for that belief in item 3, and indicate the manner in which the record should be amended to cure the inaccuracy. 2b.Record was wrongfully filed. If this Information Statement is filed based upon the belief of the Debtor of Record that the record identified in item 1 was wrongfully filed, check box in item 2b and provide the basis for that belief in item 3. 2c.Record filed by person not entitled to do so. If this Information Statement is filed based upon the belief of the Secured Party of Record that the person that filed the record identified in item 1b was not entitled to do so under Section 9-509, check box in item 2c and provide the basis for that belief in item 3. 3.Basis. Use this item to provide the basis for the box checked in item 2. 4.Filing office date and time. If this Information Statement relates to a record filed [or recorded] in a filing office described in Section 9-501(a)(1) and this Information Statement 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]. 5.Name of Authorizing Party. Enter name of the person filing this Information Statement. This name must be the same name as a Secured Party of Record or the name under which the record is indexed.