Fill and Sign the Ucc Services Online Tennessee Secretary of State Tngov Form

TN FORM UCC5 (12/1 /2016 ) Business Services Division Tre Hargett, Secretary of State State of Tennessee INSTRUCTIONS Statement of Claim (TN Form UCC5) Filing Fee: $15.00 Pursuant t o T.C.A. § 3 9 -1 7 -1 1 7 , it is a Class E f elony f or any person t o k now i ngly prepare, sign, or f ile any lien or ot her docum ent w it h t he int ent t o encum ber any real or personal proper t y w hen such person has no reasonable basis or any lega l ca use t o place such lien or encum brance on such real or personal proper t y. A blank form follows these instructions. A UCC5 Statement of Claim may be filed using one of the following methods: • E-file: Go to http://tnbear.tn.gov/UCC . Use the online tool to complete the filing and pay the filing fee b y credit card, debit card or e-check . When paying by credit card, debit card or e-check , there is a convenience fee that covers the credit card fees and transaction costs incurred by the Business Services Division when accepting online payments. Filers who do not wish to pa y the convenience fee to file online may choose the “Print and Mail” option at no additional cost. • Print and Mail: Go to http://tnbear.tn.gov/UCC . Use the online tool to complete the filing. Print and mail the application along with the required filing fee to the Secretary of State’ s office at ATTN: UCC, 312 ROSA L PARKS AVE #6, NASHVILLE TN 37243 -1102. • Paper submission: A blank follows these instructions. The form must be hand printed in black ink or computer generated and mailed along with the required filing fee to the Secretary of State’s office at ATTN: UCC, 312 ROSA L PARKS AVE #6, NASHVILLE TN 37243 -1102. • Walk -in: A blank UCC5 form may be obtained in person at the Secretary of State Business Servic es Division located on the 6 th Floor of the Snodgrass Tower at 312 Rosa L. Parks AVE, Nashville, TN 37243. Please type or laser -print this form. Be sure it is completely legible. Read all Inst ructions, especially instructions 1a and 1b; correct identification of the initial Record to which this S tatement of Claim relates is crucial. Follow i nstructions completely. Fill in form very carefully. If you have questions, consult yo ur attorney. Filing office cannot give legal advice. Do not write in any area of the form other than in the designated application box sections. To assist filing offices that might wish to communicate with filer, filer may provide information in items A and B. Complete item C if you want an acknowledgment letter returned to you with your original documents . General - You must always complete items 1 and 4 and either 2a , 2b or 2c . 1a . Initial Financing Statement File number – Enter the file number of the initial financing statement (UCC1 ) to which the Record that is the object of this Statement of Claim relates. Enter only one file number. 1b. Type of Record – Indicate the type of Record to which this Statement of Claim relates (e.g., Financing Statement or Amendment). You may also insert additional information that you believe will assist in identifying the Record (e.g. Amendment Number) . 1c. Date - Enter the date the Record to which this claim relates was filed. 1d. Time - Enter th e time the Record to which this claim relates was filed. 2. Check only one box - In no circumstance should more than one box in Item 2 be checked. 2a. RECORD is inaccurate - If this Statement of Claim is filed based on the filer ’s belief that the Record identified in item 1 is inaccurate, check box 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 Statement of Claim is filed based on the belief of the Debtor of Record that the Record identified in item 1 was wrongfully filed, check box 2b and provide the basis for that belief in item 3 . 2c. RECORD was filed by a person not entitled to do so – If th is Statement of Claim is filed based upon the belief of the Secured Party of Record that the person that filed the record identi fied in item 1b was not entitled to do so under T.C.A. § 47 -9-509(d) , check box 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. AUTHORIZING PARTY - E nter name of the Debtor /Secured Party who authorized the filing of this Statement of Claim . This name must be the same as a name under which the Record is indexed. Note: The UCC5 is attached to the record but does not correct any information on the filing. Corrections are filed using the UCC Financing Statement Amendment (TN Form UCC3). Filing Fee • The filing fee is $15. 00. • Make check, cashier’s check or money order payable to the Tennessee Secretary of State. Cash is only accepted for walk -in filings. Checks, cashier’s checks or money orders made out to any payee other than the Tennessee Secretary of State will not be a ccepted and will result in the rejection of document. STATEMENT OF CLAIM FOLLOW INSTRUCTIONS CAREFULLY1. Identi�cation of the RECORD to which this STATEMENT OF CLAIM relates. 1a. INITIAL FINANCING STATEMENT FILE NUMBER 1b. TYPE OF RECORD 1c. DATE OF INITIAL FINANCING STATEMENT 1d. TIME OF INITIAL FINANCING STATEMENT 2a. RECORD is inaccurate. Enter in item 3 the basis for the belief by the debtor of Record identi�ed in item 4 that the RECORD identi�ed in item 1 is inaccurate and indicate the manner in which the person believes the RECORD should be amended to cure the inaccuracy. 2b. RECORD was wrongfully �led. Enter in item 3 the basis for the belief by the Debtor of Record identi�ed in item 4 that the RECORD identi�ed in item 1 was wrongfully �led. 4a. ORGANIZATION’S NAME 4b. INDIVIDUAL’S SURNAME FIRST PERSONAL NAME ADDITIONAL NAME(S) INITIAL(S) SUFFIX 4. NAME OF PERSON AUTHORIZING THE FILING OF THIS STATEMENT OF CLAIM - The RECORD identi�ed in item 1 must be indexed under this name. NOTE: All information on this form is public record. STATEMENT OF CLAIM (TN FORM UCC5) (REV. 12/1/201 6) CAUTION: This is not an amendment. THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY A. NAME & PHONE OF PERSON FILING THIS STATEMENT B. EMAIL CONTACT AT FILER (Optional) C. SEND ACKNOWLEDGMENT TO: (Name and Address) OR 2c. RECORD was �led by a 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 �led the RECORD identi�ed in item 1 was not entitled to do so under T.C.A. § 47-9-509(d). 3. Provide the basis for the claim.