When recorded/filed, return to:____________________________________________ _________________________________________________________________

Sample Uniform Commercial Code 1 Financing Statement
1. Name of Debtor: ______________________________________________________________ 
Address of Debtor: ______________________________________________________________ ______________________________________________________________________________
2. Name of Secured Party: _________________________________________________________ 
Address of Secured Party: __________________________________________________________ _________________________________________________________________ 
3. This Financing Statement covers the following types (or items) of property: 
(Describe) _____________________________________________________________________ _________________________________________________________________
4. Check here ___ if collateral is crops. The above described crops are growing or are to be grown on (Describe real estate): __________________________________________. 
5. (Check here ___ if collateral is goods which are or are to become fixtures, timber to cut, or minerals or the like (including oil and gas) or accounts to be financed at the wellhead or minehead of the well or mine). The legal description of the real estate is: ________________________________ _______________________________________________________________________ and this Financing Statement is to be filed in the office where a mortgage on the real estate would be recorded. If the debtor does not have an interest of record, the name of the record owner is: ___________________________________________. 
6. Proceeds and products of collateral are also covered.
 
_____________________________________________ 
Signature of Secured Party                         

_____________________________________________ 
 Signature of Debtor