Instructions for Information Statement (Form UCC5) Fees: The Information Statement (Form UCC5) must be accompanied by a $10 fee if less than 3 pages. If 3 pages or more, the fee is $20. (Government Code section 12194) The information must be legible for digital imaging. Read and follow all Instructions. If you have questions, consult your legal counsel. The Secretary of State's office cannot give legal advice. Completed forms along with the applicable fees can be mailed to Secretary of State, UCC Section, P.O. Box 942835, Sacramento, th CA 94235-0001 or delivered in person (drop off) to the Sacramento office, 1500 11 Street, Sacramento, CA 95814. Do not insert anything in the open space in the upper portion of this form; it is reserved for filing office use only. Note: A person may file an Information Statement with respect to a record indexed under that person's name if the person believes the record was inaccurate or wrongfully filed, or a person may file an Information Statement with respect to a record if the person is a Secured Party of Record with respect to the financing statement to which the record relates and believes that the person that filed the record was not entitled to do so. ITEM INSTRUCTIONS A and B. To assist filing offices that might wish to communicate with filer, filer may provide information in item A and item B. These items are optional. C. Complete item C if filer desires an acknowledgment sent. If filing in a filing office that returns an acknowledgment copy furnished by filer, present simultaneously with this form the Acknowledgment Copy or a carbon or other copy of this form for use as an acknowledgment copy. Always complete items 1 and 5 and either 2a or 2b or 2c. Always complete item 3 with the basis for the box marked in item 2. You may also be required to complete item 4. 1a. File number: Enter file number of initial financing statement to which the record that is the object of this Information Statement relates. Enter only one file number. 1b. Enter record information to which this Information Statement relates. Indicate the type of record to which this Information Statement relates (e.g., Financing Statement or Amendment) or you may also insert additional information that you believe will assist in identifying the record (e.g., the record file number or the filing date of the record). 2a. Record is inaccurate. If this Information Statement is filed based upon the belief of the Debtor of Record that the record identified in item 1 is inaccurate, check box in item 2a, provide the basis for that belief in item 3, and indicate the manner in which the record should be amended to cure the inaccuracy. 2b. Record was wrongfully filed. If this Information Statement is filed based upon the belief of the Debtor of Record that the record identified in item 1 was wrongfully filed, check box in item 2b and provide the basis for that belief in item 3. 2c. Record filed by person not entitled to do so. If this Information Statement is filed based upon the belief of the Secured Party of Record that the person that filed the record identified in item 1b was not entitled to do so under Section 9-509, check box in item 2c and provide the basis for that belief in item 3. 1. Basis. Use this item to provide the basis for the box checked in item 2. 2. Filing office date and time. If this Information Statement relates to a record filed [or recorded] in a filing office described in Section 9-501(a)(1) and this Information Statement is filed in such a filing office, provide the date [and time] on which the initial financing statement identified in item 1a above was filed [or recorded]. 3. Name of Authorizing Party. Enter name of the person filing this Information Statement. This name must be the same name as a Secured Party of Record or the name under which the record is indexed. CAUTION: This is not an amendment. INFORMATION STATEMENT FOLLOW INSTRUCTIONS A. NAME & 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. Identification of the RECORD to which this INFORMATION STATEMENT relates 1a. INITIAL FINANCING STATEMENT FILE NUMBER 1b. RECORD INFORMATION TO WHICH THIS INFORMATION STATEMENT RELATES 2. Check one of these three boxes to indicate the claim made by this INFORMATION STATEMENT 2a. 2b. RECORD IS INACCURATE. Enter in item 3 the basis for the belief by the Debtor of Record identified in item 5 that the RECORD identified in item 1 is inaccurate and indicate the manner in which the person believes the RECORD should be amended to cure the inaccuracy RECORD WAS WRONGFULLY FILED. Enter in item 3 the basis for the belief by the Debtor of Record identified in item 5 that the RECORD identified in item 1 was wrongfully filed 2c. RECORD FILED BY PERSON NOT ENTITLED TO DO SO. Enter in item 3 the basis for the belief by the Secured Party of Record that the person that filed the RECORD identified in item 1 was not entitled to do so under UCC Section 9-509 3. Basis for claim of box checked in item 2 4. If this INFORMATION STATEMENT relates to a RECORD filed [or recorded] in a filing office described in Section 9-501(a)(1) and this INFORMATION STATEMENT is filed in such a filing office, provide the date [and time] on which the INITIAL FINANCING STATEMENT identified in item 1a above was filed [or recorded] 4a. DATE 4b. TIME 5. NAME of PERSON filing this INFORMATION STATEMENT 5a. ORGANIZATION'S NAME OR 5b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME ADDITIONAL NAME(S)/INITIAL(S) SUFFIX INFORMATION STATEMENT (Form UCC5) (Rev. 07/19/12)