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Agricultural Production Input Lien Notification Statement Form. This is a Minnesota form and can be use in Uniform Commercial Code Secretary Of State.
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Tags: Agricultural Production Input Lien Notification Statement, Minnesota Secretary Of State, Uniform Commercial Code
STATE OF MINNESOTA
AGRICULTURAL PRODUCTION INPUT LIEN
NOTIFICATION STATEMENT
STANDARD FORM
For
Filing
Officer
This statement if presented for filing pursuant to Minnesota Statutes Section 514.956.
(Type in Black Ink)
1. Individual Debtor - Last Name
First Name
Middle I.
Residential Address
City
State
2. Individual Debtor - Last Name
Zip Code
First Name
Middle I.
Residential Address
City
State
Zip Code
3. Business Debtor - Name
Mailing Address
City
4. Supplier (Secured Party) Name
5. Lender Name
Mailing Address
Mailing Address
City
State
Zip Code
6. Date or anticipated dates of the transaction
City
State
Zip Code
State
Zip Code
7. Retail cost or anticipated costs of the agricultural production input
$
8. The name and residential address of the owner and a description of the real estate where the crops to which the lien attaches are growing or are to
be grown (if applicable):
9. The name and residential address of the owner of the livestock, the location where the livestock will be raised, and a description of the livestock
(if applicable):
10. This lien notification statement covers all products of proceeds of the crops of livestock covered by the agricultural input lien. The transactions
covered by this agricultural input lien are described as follows:
RETURN ACKNOWLEDGMENT COPY TO: (name and address)
________________________________________________
Signature(s) of Person(s) to whom the Agricultural
Production Input was Provided
________________________________________________
Signature(s) of Person(s) to whom the Agricultural
Production Input was Provided
Please do not type outside the bracketed area.
(1) Filing Officer Copy - Alphabetical (10941370 Rev. 9/04) Standard Form Approved By Secretary of State
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INSTRUCTIONS FOR AGRICULTURAL INPUT LIEN-NOTIFICATION STATEMENT
THIS STATEMENT MUST BE TYPED OR LEGIBLY PRINTED IN BLACK INK ONLY.
ILLEGIBLE STATEMENTS WILL BE RETURNED WITHOUT BEING FILED.
Minnesota Relay Service
TDD (612)297-5353
General Instructions
*Review the form to make sure the information is legible. Illegible information will result in a rejected filing.
*Verify the information on the form for accuracy and correct spelling.
*If the space provided for any item on this form in inadequate, use up to four additional pages.
Specific Instructions
1. - 2. DEBTOR NAME: Provide the true and complete name of each person or organization to whom the agriculture
production input was furnished. Initials, abbreviations or nicknames are not acceptable.
1. - 2. DEBTOR ADDRESS: Provide a complete address for each debtor name listed. One address is accepted for
each debtor name. The address should reflect the residential address of the person to whom the agricultural production input was furnished.
3. SUPPLIER: Provide a complete name and mailing address of the supplier claiming the lien.
4. LENDER: Provide a complete name and business address of the lender who is to receive notification of the agricultural production input lien.
5. Provide a complete date of anticipated date of the transaction.
6. Provide the retail cost of the agricultural production input.
7. Provide a complete name and residential address of the owner of the real estate where the crops to which the lien
attaches are growing or are to be grown, if applicable. Also provide a description of the real estate, legal description
may be abbreviated. For example, 100 acres in the SW 1/4 of Twp. 112, Range 42.
8. Provide a complete name and residential address of the owner of the livestock, if applicable. Also provide the
location of the livestock (legal description is not required) and a description of the livestock.
9. Provide a description of the agricultural input and all products of proceeds of the crops or livestock covered by the
lien. For example, gasoline for planting crops and vitamins for livestock.
ACKNOWLEDGMENT NAME AND ADDRESS: Provide a complete name and mailing address where acknowledgment of filing may be sent. Failure to do so may result in a rejected filing.
SIGNATURE: The signature of the person to whom the agriculture production input was provided is required.
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