§12A-1-9-521. Uniform form of written financing statement and
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amendment.
UNIFORM FORM OF WRITTEN FINANCING STATEMENT AND AMENDMENT
(a)A filing office that accepts written records may not refuse to accept a written initial financing statement in the following form and format, except for a reason set forth in subsection
(b)of Section 1-9-516 of this title: UCC FINANCING STATEMENT FOLLOW INSTRUCTIONS A. NAME AND PHONE OF CONTACT AT FILER (optional)
_____________________________________________ B. E-MAIL CONTACT AT FILER (optional) C. SEND ACKNOWLEDGMENT TO: (Name and Address)
________________________________________
________________________________________ THE ABOVE SPACE IS FOR
________________________________________ FILING OFFICE USE ONLY 1. DEBTOR'S NAME – provide only one Debtor name (1a or 1b) – (use
exact, full name; do not omit, modify, or abbreviate any word
in the Debtor's name)
1a. ORGANIZATION'S NAME
_______________________________________________________________ OR 1b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS
DEBTOR SUFFIX
________________________________________ _______________
1c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY
_______________________________________________________________ 2. DEBTOR'S NAME – provide only one Debtor name (2a or 2b)(use
exact, full name; do not omit, modify, or abbreviate any word
in the Debtor's name)
2a. ORGANIZATION'S NAME
_______________________________________________________________ OR 2b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS
DEBTOR SUFFIX
________________________________________ _______________
2c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY
_______________________________________________________________ 3. SECURED PARTY'S NAME (or NAME of ASSIGNEE of ASSIGNOR SECURED
PARTY) – provide only one Secured Party name (3a or 3b)
3a. ORGANIZATION'S NAME
______________________________________________________________ OR 3b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) SUFFIX
________________________________________ __________________
3c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY
_______________________________________________________________ 4. COLLATERAL: This financing statement covers the following
collateral:
_______________________________________________________________ 5. Check only if applicable and check only one box:
Collateral is: [ ] held in a Trust (see instructions)
[ ] being administered by a Decedent's
Personal Representative.
6a. Check only if applicable and check only one box:
[ ] Public-Finance Transaction
[ ] Manufactured-Home Transaction
[ ] A Debtor is a Transmitting Utility
6b. Check only if applicable and check only one box:
[ ] Agricultural Lien [ ] Non-UCC Filing 7. ALTERNATIVE DESIGNATION (if applicable):
[ ] Lessee/Lessor
[ ] Consignee/Consignor
[ ] Seller/Buyer
[ ] Bailee/Bailor
[ ] Licensee/Licensor 8. OPTIONAL FILER REFERENCE DATA
_______________________________________________________________ UCC FINANCING STATEMENT (Form UCCI) UCC FINANCING STATEMENT ADDENDUM FOLLOW INSTRUCTIONS 9. NAME OF FIRST DEBTOR (same as item 1a or 1b on Financing
Statement)
9a. ORGANIZATION'S NAME
_______________________________________________________________ OR 9b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_________________________ __________________________
ADDITIONAL NAME(S)/INITIAL(S) SUFFIX
________________________________________ _______
________________________________________ THE ABOVE SPACE IS FOR
________________________________________ FILING OFFICE USE ONLY 10. ADDITIONAL DEBTOR'S NAME – provide only one Debtor name (10a or
10b) - (use exact, full name; do not omit, modify, or
abbreviate any word in the Debtor's name)
10a. ORGANIZATION'S NAME
_______________________________________________________________ OR 10b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
___________________________ ___________________________
ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS
DEBTOR SUFFIX
________________________________________ _______________
10c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY
_______________________________________________________________ 11. [ ] ADDITIONAL SECURED PARTY'S NAME or [ ] ASSIGNOR SECURED
PARTY'S NAME – provide only one name (11a or 11b)
11a. ORGANIZATION'S NAME
_______________________________________________________________ OR 11b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) SUFFIX
_______________________________________________ _______
11c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY
_______________________________________________________________ 12. ADDITIONAL SPACE FOR ITEM 4 (Collateral)
______________________________________________________________ 13. This FINANCING STATEMENT is to be filed (for record) (or
recorded) in the REAL ESTATE RECORDS (if applicable) 14. This FINANCING STATEMENT:
[ ] covers timber to be cut [ ] covers as-extracted
collateral [ ] is filed as a fixture filing 15. Name and address of a RECORD OWNER of the real estate described
in item 16 (if Debtor does not have record interest):
_______________________________________________________________ 16. Description of real estate:
_______________________________________________________________ 17. MISCELLANEOUS:
______________________________________________________________
(b)A filing office that accepts written records for filing may not refuse to accept a written financing statement amendment in the following form, except for a reason set forth in subsection
(b)of Section 1-9-516 of this title: UCC FINANCING STATEMENT AMENDMENT FOLLOW INSTRUCTIONS A. NAME AND PHONE OF CONTACT AT FILER (optional)
_______________________________________________________________ B. E-MAIL CONTACT AT FILER (optional)
_______________________________________________________________ C. SEND ACKNOWLEDGMENT TO: (Name and Address)
_______________________________________
_______________________________________ THE ABOVE SPACE IS FOR
_______________________________________ FILING OFFICE USE ONLY
1a. INITIAL FINANCING STATEMENT FILE NUMBER
_______________________________________________________________
1b. [ ] This FINANCING STATEMENT AMENDMENT is to be filed (for
record) (or recorded) in the REAL ESTATE RECORDS.
Filer: attach Amendment Addendum (Form UCC3Ad) and provide
Debtor's name in item 13.
2. [ ] TERMINATION: Effectiveness of the Financing Statement
identified above is terminated with respect to security
interest(s) of Secured Party authorizing this Termination
Statement. 3. [ ] ASSIGNMENT (full or partial): Provide name of Assignee in
item 7a or 7b, and address of Assignee in item 7c and name of
Assignor in item 9. For partial assignment, complete items 7
and 9 and also indicate affected collateral in item 8. 4. [ ] CONTINUATION: Effectiveness of the Financing Statement
identified above with respect to security interest(s) of
Secured Party authorizing this Continuation Statement is
continued for the additional period provided by applicable law. 5. [ ] PARTY INFORMATION CHANGE:
Check one of these two boxes:
This Change affects [ ] Debtor or [ ] Secured Party of
record.
AND
Check one of these three boxes to:
[ ] CHANGE name and/or address: Complete item 6a or 6b, and
item 7a or 7b and item 7c.
[ ] ADD name: Complete item 7a or 7b, and item 7c.
[ ] DELETE name: Give record name to be deleted in item 6a or
6b. 6. CURRENT RECORD INFORMATION: Complete for Party Information
Change – provide only one name (6a or 6b) (use exact, full
name; do not omit, modify, or abbreviate any word in the
Debtor's name).
6a. ORGANIZATION'S NAME
_______________________________________________________________ OR 6b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) SUFFIX
___________________________________ __________________ 7. CHANGED OR ADDED INFORMATION: Complete for Assignment or Party
Information Change – provide only one name (7a or 7b) (use
exact full name; do not omit, modify, or abbreviate any word in
the Debtor's name).
7a. ORGANIZATION'S NAME
_______________________________________________________________ OR 7b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) THAT ARE PART OF THE NAME OF THIS
DEBTOR SUFFIX
_______________________________________________________________
7c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY
_______________________________________________________________ 8. [ ] COLLATERAL CHANGE:
_______________________________________________________________
Also check one of these four boxes:
[ ] ADD collateral [ ] DELETE collateral [ ] RESTATE
covered collateral [ ] ASSIGN collateral
Indicate collateral:
_______________________________________________________________ 9. NAME OF SECURED PARTY OF RECORD AUTHORIZING THIS AMENDMENT -
provide only one name (9a or 9b) (name of Assignor, if this is
an Assignment).
If this is an Amendment authorized by a DEBTOR, check here [ ]
and provide name of authorizing Debtor.
9a. ORGANIZATION'S NAME
_______________________________________________________________ OR 9b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) SUFFIX
___________________________________ _____________ 10. OPTIONAL FILE REFERENCE DATA
_______________________________________________________________ UCC FINANCING STATEMENT AMENDMENT (FORM UCC3) UCC FINANCING STATEMENT AMENDMENT ADDENDUM FOLLOW INSTRUCTIONS 11. INITIAL FINANCING STATEMENT FILE NUMBER (same as item 1a on
Amendment form).
_______________________________________________________________ 12. NAME OF PARTY AUTHORIZING THIS AMENDMENT (same as item 9 on
Amendment form).
12a. ORGANIZATION'S NAME
_______________________________________________________________ OR 12b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) SUFFIX
________________________________________ _____________
________________________________________ THE ABOVE SPACE IS FOR
________________________________________ FILING OFFICE USE ONLY 13. Name of DEBTOR on related financing statement (Name of a
current Debtor of record required for indexing purposes only in
some filing offices – see Instruction for item 13 – insert only
one Debtor name (13a or 13b) (use exact, full name; do not
omit, modify, or abbreviate any word in the Debtor's name).
13a. ORGANIZATION'S NAME.
_______________________________________________________________ OR 13b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME
_______________________________________________________________
ADDITIONAL NAME(S)/INITIAL(S) SUFFIX
_____________________________________ _____________ 14. ADDITIONAL SPACE FOR ITEM 8 (Collateral)
_____________________________________________________________ 15. This FINANCING STATEMENT AMENDMENT: [ ] covers timber to be
cut [ ] covers as-extracted collateral [ ] is filed as a
fixture filing. 16. Name and address of a RECORD OWNER of real estate described in
item 17 (if Debtor does not have a record interest):
______________________________________________________________ 17. Description of real estate:
______________________________________________________________ 18. MISCELLANEOUS:
______________________________________________________________ UCC FINANCING STATEMENT AMENDMENT ADDENDUM (Form UCC3Ad)
(c)A form that a filing office may not refuse to accept under subsection
(a)or
(b)of this section must conform to the format prescribed for the form by the National Conference of Commissioners on Uniform State Laws. Added by Laws 2000, c. 371, § 99, eff. July 1, 2001. Amended by Laws 2015, c. 374, § 15, eff. Nov. 1, 2015.