STATE OF MINNESOTA EFFECTIVE FINANCING STATEMENT (EFS)/ STATUTORY LIEN NOTICE CNS-1 FORM For Filing Officer This statement is presented for filing pursuant to Minnesota Statutes Chapter 336A. (Type in Black Ink) 1. Individual Debtor Last Name Social Security # City 2. Individual Debtor Last Name Social Security # City 3. Business Debtor Name First Name Mailing Address State First Name Mailing Address State Middle I. Zip Code Middle I. Zip Code Fed. ID # City 4. Secured Party/Lienholder Name Mailing Address State Zip Code 5. "THE INFORMATION CONTAINED IN AN EFFECTIVE FINANCING STATEMENT WILL BE SENT TO FARM PRODUCT BUYERS REGISTERED Mailing Address IN MINNESOTA. SALE OF FARM PRODUCTS TO THOSE BUYERS MAY RESULT IN A CHECK City State Zip BEING ISSUED PAYABLE JOINTLY TO BOTH THE SELLER AND THE SECURED PARTY." 6. Farm Product Description (See General Instructions for information on when you should check the Statutory Lien box below.) This form is EFS unless the Statutory Lien box is marked. Lien Conditions for waiver or release: ___________________________________________________ Product Code 1. 2. 3. ________ ________ ________ Quantity Crop Year ________ ________ ________ County Code ______________ ______________ ______________ Property Description (optional and not required) Section(s) Township Range _______________ _______________ _______________ ________ ________ ________ ________ ________ ________ Statutory ________ ________ ________ I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the person(s) whose signature would be required on behalf of the previous holder of this name, who has authorized me to sign this document on his/her behalf. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath. Name of Contact: Phone Number: RETURN ACKNOWLEDGMENT COPY TO: (name and address) Email Address: Signatures are on file with the secured party. ________________________________________________ Debtor's Signature ________________________________________________ Debtor's Signature ________________________________________________ Lienholder/Secured Party Signature Standard Form Approved by Secretary of State American LegalNet, Inc. www.FormsWorkFlow.com Name: Street: City: State: Zip Code: Please do not type outside the bracketed area EFFECTIVE FINANCING STATEMENT/STATUTORY LIEN STATEMENT CNS-1 FORM INSTRUCTIONS THIS STATEMENT MUST BE TYPED OR LEGIBLY PRINTED IN BLACK INK ONLY ILLEGIBLE STATEMENTS WILL BE RETURNED WITHOUT BEING FILED. 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 is inadequate, use up to four additional pages. This form is an EFS unless the Statutory Lien box is marked. A statutory lien is filed by the lienholder (i.e. veterinarian, crop sprayer, landlord) to protect their security interests for services or materials rendered. Pursuant to 336A.01, subd.11, a farm products statutory lien is one arising under one of the following sections of Minnesota Statute: 336A.9-102(a)(5), 514.963, subd.3, 514.065, subd.3 or 514.945. A statutory lienholder has the right to put conditions on the release or waiver of the lien which support this filing. Use the space provided to describe any such conditions. For example, the lienholder may require that a joint check be issued to all involved parties. SPECIFIC INSTRUCTIONS DEBTOR NAME: Boxes 1-3 Provide the true and complete name of the debtor. Initials, abbreviations are not acceptable. List individual debtor names and business debtor names in the appropriate boxes. Failure to do so will result in a rejected filing. The debtor name will be indexed exactly as it appears in the debtor box. A social security number or tax identification number is required for each debtor name listed on an effective financing statement. A statutory lien does NOT require an SSN/FEIN number. Provision of social security number or Federal ID number on the CNS form may require this notice according to federal and state law: The disclosure of the social security number or Federal ID number on this form is required under state law, Minnesota Statutes Section 336.9-402 et.seq. The information will be used to distinguish between individuals with the same or similar names who have records about financial transaction filed with the secretary of state. Failure to provide the required information will prevent the filing of the Central Notification System documents and may ultimately prevent the debtor from receiving a loan or the accrual of other benefits pursuant to the document. NOTE: Effective 10/31/2010, pursuant to Minnesota Statutes 336A.14, a Social Security number (SSN) maintained by the secretary of state under this section is private data on individuals or nonpublic data as defined in section 13.02, and therefore the SSN will be redacted on the file stamped copy returned to you. As a result of the law change effective 10/31/2010, pursuant to 336A.08, there will be a Unique ID assigned to each debtor in place of the SSN/FEIN. This unique ID information will be provided to you along with your stamped copy. Please keep this information for your records for future verification. Persons or entities authorized to receive the social security number information include those persons in the office of the Secretary of State whose work assignments reasonably require access and those who are authorized by the individual with the affected social security number. DEBTOR ADDRESS: Boxes 1-3 Provide a complete name and mailing address for each debtor name listed. SECURED PARTY: Box 4 Provide a complete name and mailing address for the secured party or lienholder. The language in box 5 does not apply to statutory liens. FARM PRODUCT DESCRIPTION: Box 6 Describe each farm product listing: 1. Product Code: The table of product codes is on page 3. 2. Quantity: The amount/quantity of the farm product, if applicable. The amount/quantity may be the number of acres, the number of bushels or any other accepted method of coun