Hospital Lien Filing Form
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Hospital Lien Filing Form. This is a Colorado form and can be use in Uniform Commercial Code Secretary Of State.
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Tags: Hospital Lien Filing Form, 054, Colorado Secretary Of State, Uniform Commercial Code
Mail to: Secretary of State
UCC Section
1700 Broadway, Suite 200
Denver, CO 80290
For Office Use Only
Please include a typed self-addressed envelope.
MUST BE TYPED
FILING FEE: $15.00
MUST SUBMIT TWO COPIES
HOSPITAL LIEN FILING FORM
You must check one of the following boxes that describes the type of document you are filing:
Original Hospital Lien
Amendment to Original Hospital Lien
Termination of Original Hospital Lien
If you check the “Amendment” or “Termination” box, you MUST include the original filing number
on file with the Secretary of State on the following line:
Original Filing Number
_____________________
Date of Injury
_____________________
Injured Person / Responsible Party _________________________________________________
Address
_________________________________________________
(Street)
(Apt. #)
_________________________________________________
(City)
(State)
(Zip Code)
Person Allegedly Liable for Injuries _________________________________________________
Hospital
_________________________________________________
Address
_________________________________________________
(Street)
(Apt. #)
_________________________________________________
(City)
Signature of Filer
(Zip Code)
_____________________
Date
(State)
_____________________
Form054
Rev.8/22/2008
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