Contact Information Kansas Secretary of State Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 kssos@sos.ks.gov www.sos.ks.gov Agriculture Production Input Lien KANSAS SECRETARY OF STATE UCC-4 All information must be completed or this document will not be accepted for filing. 1. Name and residential address of agricultural input purchaser: Name Street Address City State Zip 2. Name and address of supplier claiming lien: Name Street Address City State Zip 3. Date or anticipated date of furnishing the input: 4. Description of the input: 5. Retail cost or anticipated retail cost of input: $ 6. Name and residential address of crop owner (if different from purchaser): Name Street Address City State Zip 7. Name and business address of lender: Name Street Address City State Zip 8. Description of real estate where crops are growing or will be grown (if applicable): Note: The products or proceeds of the crops are covered by the lien. 9. Describe livestock and location where they will be or are being raised or fed (if applicable): Note: The products or proceeds of the livestock are covered by the lien. Purchaser's Signature Day Month Year Supplier's Signature By signing here, the undersigned certifies that the lender has not responded to the lien notification statement Date notice sent to lender Day Month Year 1/2 American LegalNet, Inc. www.FormsWorkFlow.com Instructions 1. If the space provided for any item is inadequate, additional pages may be attached. 2. Mail a copy of this notice by certified mail or another method evidencing date of receipt to the lender in an envelope marked "IMPORTANT LEGAL NOTICE." 3. The lender has five business days after receipt of notice to respond with a letter of commitment to advance part or all of the retail cost stated in the lien notification statement or issue a written refusal to furnish the letter of commitment. 4. If the lender fails to respond within five business days, file the original form with the secretary of state within 20 days after the last date that agricultural production input was furnished. The filing fee is $20.00. Include an additional $1.00 for each page in excess of ten pages. 5. A UCC-1 financing statement and addendum must accompany this form. List the "purchaser" as the "debtor" and the "supplier" as the "secured party" on the UCC-1 form. Also, state in box 10 on the addendum that the form is filed pursuant to KSA 58-244. Rev. 3/31/10 jdr K.S.A. 58-242 2/2 American LegalNet, Inc. www.FormsWorkFlow.com