FRAUDULENT UCC FINANCING STATEMENT AFFIDAVIT Financing Statement must have been filed with the Michigan Secretary of State UCC Office FOLLOW INSTRUCTIONS (front and back) CAREFULLY A. Name & Phone (including area code) of Person Filing This Affidavit B. SEND ACKNOWLEDGEMENT TO: (Name and Address) 1. Record to Which This Affidavit Relates: 1a. RECORD TYPE (Check One) (Found in the upper left hand corner of the financing statement.) A R12345 UCC Financing Statement (UCC1 or UCC1ad) UCC Financing Statement Amendment (UCC3 or UCC3ad) THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 1b. MICHIGAN FINANCING STATEMENT FILING NUMBER (Found in the upper right hand corner of the financing statement. Example: 2009000001-0) 2. Name Of Person Filing This Affidavit - The Record Identified In Item 1 Must Indicate This Person As Debtor. 2a. ORGANIZATION'S NAME OR 2b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX 3. Record is fraudulent. (Provide a statement explaining why the record identified in Item 1 is fraudulent. Attach extra pages if needed.) 4. I certify under penalty of law that the information provided is true, correct, and complete, and I give notice that the financing statement referenced above is fraudulent. Affiant Signature: _______________________________________________ Title: ______________ Date: _____________ (The Record Identified In Item 1 Must Indicate This Person As DEBTOR.) (If representing an organization) Subscribed and sworn to before me on the ________ day of ____________________, ________ _____________________________________________________________________________ (Notary Public Signature) _____________________________________________________________________________ (Notary Public Printed Name) Notary Public, State of Michigan, County of __________________________________________ My commission expires __________________________ Acting in the County of _____________ An individual who files a materially false or fraudulent UCC Financing Statement Affidavit is guilty of a felony punishable by imprisonment for not more than 5 years or a $2,500 fine, or both. [MCL 440.9501a(9)] A recorded Fraudulent UCC Financing Statement Affidavit terminates the identified financing statement. [MCL 440.9501a(3)] FORM MIUCC7 03/09 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Fraudulent UCC Financing Statement Affidavit (Form MIUCC7) Please type or legibly print this form. Follow all instructions. Complete the form carefully; mistakes may have important legal consequences. If you have questions, consult your attorney. The filing office cannot give legal advice. Do not insert anything in the open space located on the upper right hand portion of this form; it is reserved for filing office use only. This affidavit cannot be filed against a financing statement filed by a regulated financial institution or its representative. A regulated financial institution is a financial institution subject to regulatory oversight or examination by a state or federal agency. Regulated financial institution includes, but is not limited to, a bank, savings bank, savings association, building and loan association, credit union, consumer finance company, industrial bank, industrial loan company, insurance company, investment company, installment seller, mortgage servicer, sales finance company, or leasing company. A. Name & Phone of Person filing This Statement: If the filing office needs to contact the filer, provide a name and phone number where the filer may be reached during normal business hours. Include the area code. B. Send Acknowledgement To: Enter the name and address where you want the acknowledgment of affidavit filing mailed. 1a. Record Type: Check the type of UCC Financing Statement filed against you as debtor. A copy of the financing statement was sent with the Debtor Notification Letter. The record type can be found in the upper left hand corner of the financing statement. 1b. Michigan Financing Statement Filing Number: To terminate the correct record, the filing office needs the complete Michigan UCC Financing Statement filing number. An example of a filing number is 2009000001-0, found in the upper right hand corner on the copy of the financing statement that was sent with the Debtor Notification Letter. The financing statement must have been filed with the Michigan Secretary of State UCC Office. This Mail the completed affidavit to: affidavit must relate to only one financing statement. Do not enter more than one file number in item 1b. 2. Name of PERSON filing this AFFIDAVIT: The person filing a Fraudulent UCC Financing Statement Affidavit must be identified as the debtor on the copy of the financing statement sent with the Debtor Notification Letter. Only the named debtor may file. If the person is an organization, complete 2a. If the person is an individual, complete 2b. 3. RECORD is fraudulent: Provide a statement explaining why the record identified in Item 1 is fraudulent. 4. Certification: Read the certification carefully. If you are the person named as debtor in the financing statement sent with the Debtor Notification Letter, and you agree with the certification statement, sign and date the Fraudulent UCC Financing Statement Affidavit. If signing for an organization, include signer's title. An unsigned or incomplete Fraudulent UCC Financing Statement Affidavit will be rejected. Michigan Department of State UCC Office PO Box 30197 Lansing, Michigan 48909-7697 03/09 American LegalNet, Inc. www.FormsWorkFlow.com