FINANCING STATEMENT ____________________________________________________________ Debtor (Last Name First/Individual) Social Security Number ____________________________________________________________ Mailing Address City, State Zip Code ____________________________________________________________ Additional Debtor - (If Any) Social Security Number ____________________________________________________________ Mailing Address City, State Zip Code ____________________________________________________________ Debtor's Trade Names or Styles Federal Tax Number ____________________________________________________________ Secured Party Social Security No. Name Federal Tax No. or Address Bank Transit and City, State A.B.A. No. Zip Code ____________________________________________________________ Assignee of Secured Party Social Security No. Name Federal Tax No. or Address Bank Transit and City, State A.B.A. No. Zip Code ____________________________________________________________ This FINANCING STATEMENT covers the following types or items of property (include description of real property on which located and owner of record when required). ____________________________________________________________ Products of Collateral are also covered Yes______No______ ____________________________________________________________ Debtor is a "Transmitting Utility" Yes______No______ ____________________________________________________________ Date: Signature(s) of Debtor(s) _____________________________________________________________ Type or Print Name of Debtor _____________________________________________________________ Signature(s) of Secured Party(ies) _____________________________________________________________ Type or Print Name of Secured Party _____________________________________________________________ Return Copy to: _____________________________________________________________
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