UCC FINANCING STATEMENT

FOLLOW INSTRUCTIONS (front and back) CAREFULLY

A. NAME & PHONE OF CONTACT AT FILER [optional]

John Henry Smith

(123) 555-1212

B. SEND ACKNOWLEDGEMENT TO:

(Name and Address)

John Henry Smith

P.O. Box 21
The City, CA 90210

THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY

1. DEBTORS EXACT FULL LEGAL NAME insert only one debtor name (1a or 1b) do not abbreviate or combine names
1a. ORGANIZATIONS NAME
OR
1b. INDIVIDUALS LAST NAME

FIRST NAME

MIDDLE NAME

Smith

John

Henry

1c. MAILING ADDRESS

CITY

STATE

P.O. Box 21

The City
ADDL INFO RE
ORGANIZATION
DEBTOR

1e. TYPE OF ORGANIZATION

SUFFIX

POSTAL CODE

1f. JURISDICTION OF ORGANIZATION

COUNTRY

90210

CA

1g. ORGANIZATIONAL ID#, if any

NONE

2. ADDITIONAL DEBTORS EXACT FULL LEGAL NAME insert only one debtor name (2a or 2b) do not abbreviate or combine names
2a. ORGANIZATIONS NAME
OR
2b. INDIVIDUALS LAST NAME

2c. MAILING ADDRESS

ADDL INFO RE
ORGANIZATION
DEBTOR

2e. TYPE OF ORGANIZATION

FIRST NAME

MIDDLE NAME

SUFFIX

CITY

STATE

COUNTRY

2f. JURISDICTION OF ORGANIZATION

2g. ORGANIZATIONAL ID#, if any

POSTAL CODE

NONE

3. SECURED PARTYS NAME (or NAME of TOTAL ASSIGNEE of ASSIGNOR S/P) insert only one secured party name (3a or 3b)
3a. ORGANIZATIONS NAME
OR

JOHN H SMITH
3b. INDIVIDUALS LAST NAME

FIRST NAME

MIDDLE NAME

3c. MAILING ADDRESS

CITY

STATE

2121 Some Street

The City

SUFFIX

POSTAL CODE

CA

COUNTRY

90210

4. This FINANCING STATEMENT covers the following collateral:

THIS IS ACTUAL AND CONSTRUCTIVE NOTICE

ALL RECORDED PROPERTY (REAL/PERSONAL) BELONGING TO THE BAILOR IS HEREBY PLACED INTO TRUST WITH
THE BAILEE. ALL UN-RECORDED PROPERTY (REAL/PERSONAL) BELONGING TO THE BAILOR IS HEREBY PLACED
INTO TRUST WITH THE BAILEE.
ALL RELATIONS AND AGREEMENTS BETWEEN THE BAILOR AND THE BAILEE ARE COVERED IN THE FOLLOWING
PRIVATE DOCUMENTS:
1) CONTRACT OF BAILMENT NO. JHS-1001-CB
2) POWER OF ATTORNEY NO. JHS-1001-PA

5. ALTERNATIVE DESIGNATION [if applicable]:

LESSEE/LESSOR

CONSIGNEE/CONSIGNOR

This FINANCING STATEMENT is to be filed [for record] (or recorded) in

the REAL ESTATE RECORDS. Attach Addendum
[if applicable]
8. OPTIONAL FILER REFERENCE DATA
6.

BAILEE/BAILOR

SELLER/BUYER

7. Check to REQUEST SEARCH REPORT(S) on Debtor(s)

[ADDITIONAL FEE]
[optional]

FILING OFFICE COPY NATIONAL UCC FINANCING STATEMENT (FORM UCC1) CALIFORNIA (REV. 01/01/08)

AG. LIEN

All Debtors

NON-UCC FILING
Debtor 1

Debtor 2

UCC FINANCING STATEMENT ADDENDUM

FOLLOW INSTRUCTIONS (front and back) CAREFULLY
9. NAME OF FIRST DEBTOR (1a or 1b) ON RELATED FINANCING STATEMENT
9a. ORGANIZATION NAME

OR

9b. INDIVIDUALS LAST NAME

FIRST NAME

MIDDLE NAME, SUFFIX

Smith

John

Henry

10. MISCELLANEOUS:

THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY

11. ADDITIONAL DEBTORS EXACT FULL LEGAL NAME insert only one name (11a or 11b) do not abbreviate or combine names
11a. ORGANIZATIONS NAME
OR
11b. INDIVIDUALS LAST NAME

11c. MAILING ADDRESS

ADDL INFO RE
ORGANIZATION
DEBTOR

12.

11e. TYPE OF ORGANIZATION

FIRST NAME

MIDDLE NAME

SUFFIX

CITY

STATE

COUNTRY

11f. JURISDICTION OF ORGANIZATION

11g. ORGANIZATIONAL ID#, if any

POSTAL CODE

NONE

ADDITIONAL SECURED PARTYS or

ASSIGNOR S/Ps NAME insert only one name (12a or 12b)

12a. ORGANIZATIONS NAME

OR
12b. INDIVIDUALS LAST NAME

12c. MAILING ADDRESS

13. This FINANCING STATEMENT covers

collateral, or is filed as a
14. Description of real estate:

timber to be cut or

as-extracted

FIRST NAME

MIDDLE NAME

SUFFIX

CITY

STATE

COUNTRY

POSTAL CODE

16. Additional collateral description:

fixture filing.

15. Name and address of a RECORD OWNER of above-described real estate

(if Debtor does not have a record interest):

17. Check only if applicable and check only one box.

Debtor is a

Trust or

Trustee acting with respect to property held in trust or

18. Check only if applicable and check only one box.

Debtor is a TRANSMITTING UTILITY
Filed in connection with a Manufactured-Home Transaction effective 30 years
Filed in connection with a Public-Finance Transaction effective 30 years

FILING OFFICE COPY NATIONAL UCC FINANCING STATEMENT ADDENDUM (FORM UCC1Ad) CALIFORNIA (REV. 01/01/08)

Decedents Estate