Fill and Sign the Notice Produce Form

430 (Rev. 9/06) Secretary of State Corporation Division - UCC 255 Capitol St. NE, Ste. 151 Salem, OR 97310-1327 Phone: (503) 986-2200 F ax: (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 parties upon request and it may be posted on our website. Please Type or Print Legibly in Black Ink. Attach Additional Sheet if Necessary. DEBTOR C HECK O NE If Individual , list last name first . 430 (Rev. 9/06)P URCHASER : NAME 1       - Business - Individual NAME 2       - Business - Individual       ADDRESS                   CITY STATE ZIPCODE P RODUCER :       NAME       ADDRESS 430 (Rev. 9/06)                   CITY STATE ZIPCODE S TATEMENT A MOUNT OF P RODUCER ’ S D EMAND ( after Deducting All Credits and Offsets) : $       D ESCRIPTION OF P RODUCE D ELIVERED OR T RANSFERRED B Y :             D ATE P AYMENT O RIGINALLY D UE :       430 (Rev. 9/06) I ( WE )       swear/affirm that the amount claimed on this Notice is a true and bona fide existing debt as of the date of this filing. S TATE OF       C LAIMANT S IGNATURE       C OUNTY OF       D ATE S UBSCRIBED TO AND SWORN / AFFIRMED BEFORE ME THIS       DAY OF       , 20       , by       430 (Rev. 9/06) Notary Public of Oregon My commission expires: RETURN TO (Please Type or Print within the box):                         FEES Required Processing Fee - $10 Processing Fees are nonrefundable. Please make check payable to “Corporation Division.” NOTE: Fees may be paid with VISA or MasterCard. The card number and expiration date should be submitted on a separate sheet for your protection. 430 (Rev. 9/06)