Mail to: Secretary of State UCC Division 450 N Jefferson 700 W 4th PO Box 83720 Boise ID 83720-0080 Telephone: 208-334-3191 Fax: 208-334-2847 Instructions: 1. Please type and sign this form in black. 2. File only the original. Make copies for your file. The original will be returned as your acknowledgment. 3. Enter only one debtor’s name or assumed name per debtor block exactly as it is to be indexed. If more than four names, use an attached sheet. 4. When the obligation has been satisfied, complete the Termination Statement and return the original to the filing officer. This block for Filing Office use only. STATE OF IDAHO - COUNTY MEDICAL - FORM N1 Name or business name of each debtor against whom the lien is claimed, and the address of each. 1 First Name Middle Name Address City State 2 First Name Middle Name City State First Name Middle Name Address City State 4 First Name Middle Name City State Organization or Indiv. Last Name Organization or Indiv. Last Name Address 3 Organization or Indiv. Last Name Organization or Indiv. Last Name Address Suffix Zip Suffix Zip Suffix Zip Suffix Zip Secured Party Name and Address Organization or Indiv. Last Name First Name Middle Name Address City State Zip Assignee Name and Address Organization or Indiv. Last Name First Name Middle Name Address City State Zip Acknowledgment Name and Address, if not Secured Party Organization or Indiv. Last Name First Name Middle Name Address City State Zip This financing statement covers the following types or items of property: Signature of Secured Party: TERMINATION STATEMENT The Secured Party no longer claims a security interest under the financing statement. Signature of Secured Party / Assignee of Record Rev. 07/2001 Date American LegalNet, Inc. www.FormsWorkflow.com