STATE OF FLORIDA UNIFORM COMMERCIAL CODE FINANCING STATEMENT FORM
A. NAME DAYTIME PHONE NUMBER OF CONTACT PERSON
B. Email Address
C. SEND ACKNOWLEDMENT TO:
Name
Address
Address
City/State/Zip
THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY
1. DEBTOR'S EXACT FULL LEGAL NAME NAME
INSERT ONLY
ONE
DEBTOR NAME
(1a OR 1B
) -Do Not Addreviate or Combine Names
1a. ORGANIZATION'S NAME
1b. INDIVIDUAL'S SURNAME
FIRST PERSONAL NAME
ADDITIONAL NAME(S)/INITIALS(S)
SUFFIX
1c. MAILING ADDRESS Line One
This space is not available.
MAILING ADDRESS Line Two
CITY
STATE
POSTAL CODE
COUNTRY
2. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME NAME
INSERT ONLY
ONE
DEBTOR NAME
(2a OR 2B
) -Do Not Addreviate or Combine Names
2a. ORGANIZATION'S NAME
2b. INDIVIDUAL'S SURNAME
FIRST PERSONAL NAME
ADDITIONAL NAME(S)/INITIALS(S)
SUFFIX
2c. MAILING ADDRESS Line One
This space is not available.
MAILING ADDRESS Line Two
CITY
STATE
POSTAL CODE
COUNTRY
3. SECURED PARTY'S NAME (
or Name of TOTAL ASSIGNEE of ASSIGNOR S/P) - INSERT ONLY
ONE
SECRED PARTY (
3a OR 3b
)
3a. ORGANIZATION'S NAME
3b. INDIVIDUAL'S SURNAME
FIRST PERSONAL NAME
ADDITIONAL NAME(S)/INITIALS(S)
SUFFIX
3c. MAILING ADDRESS Line One
This space is not available.
MAILING ADDRESS Line Two
CITY
STATE
POSTAL CODE
COUNTRY
This
FINANCING STATEMENT
covers the folowing collateral:
5.
ALTERNATE DESIGNATIONB (if applicable)
LESSEE/LESSOR
CONSIGNEE/CONSIGNOR
BAILEE/BAILOR
AG LIEN
NON-UCC FILING
SELLER/BUYER
6.
Florida DOCUMENTARY STAMP TAX
- YOU ARE REQUIRED TO CHECK
EXACTLY ONE BOX
All documentary stamls due payable or to become due abd payable pursuant tp s.201.22.F.S., have been paid.
Florida Documanetary Stamp Tax is not required.
7. Optional Filer Reference Data
STANDARD FORM - UCC-1 (REV.05/2013)
Filing Office Copy
Approved by the Secretary of State, State of Florida