Form UCC Uniform Commercial Code Act Affidavit of Compliance for Service on Secretary of State August 2012 Secretary of State Department of Business Services UCC Division 501 S. Second St., Rm. 350W Springfield, IL 62756 SUBMIT IN DUPLICATE Type or Print Clearly. www.cyberdriveillinois.com This space for use by Secretary of State. Payment must be made by certified check, cashierʼs check, money order, Illinois attorneyʼs check or Illinois C.P.A.ʼs check. File Number: Date: Approved: This space for use by Secretary of State. 1. Affiant Name: ______________________________________________________________ 2. Financing Statement/Amendment Number Listing Affiant as a Debtor: 3. I hereby affirm my reasonable belief that the aforementioned filing (initial each): a. _____ is not authorized or permitted under Section 9-509, 9-708, or 9-808 of the Uniform Commercial Code (810 ILCS 5); b. _____ is not related to a valid existing or potential commercial or financial transaction, an existing agricultural or other lien, or a judgment of a court of competent jurisdiction; and c. _____ is filed with intent to harass or defraud me and/or other person(s). 4. The undersigned affirms, under penalties of perjury, that the facts stated herein are true, correct and complete. ______________________________________ Signature of Affiant ________________ Month & Day ________________ Year Affiant Contact Information (please type or print clearly): __________________________________________ Name __________________________________________ Street __________________________________________ City State ZIP ____________________________________ Telephone Number ____________________________________ Email Address Printed by authority of the State of Illinois. September 2012 — 500 — UCC 57 American LegalNet, Inc. www.FormsWorkFlow.com