For Filing Officer STATE OF MINNESOTA UCC-12 REQUEST FOR TAX LIEN INFORMATION OR COPIES This statement is presented pursuant to Minnesota Statutes Sections 270C.63, 272.483 and 336.9-523. (Type in Black Ink) OPTIONS (choose one); SEARCH IS OF RECORDS OF SINGLE FILING OFFICE ONLY. □ INFORMATION LISTING ONLY (Includes state and federal tax liens showing all taxpayer names and addresses, government entity, filing information and description of subsequent filings). □ □ COPIES ONLY (Includes state and federal tax liens showing the file number, the file date and copies of the tax liens that are filed in the filing office where the request was processed). COMBINATION INFORMATION AND COPIES (Includes data as described in information option and copies of the tax liens that are filed in the filing office where the request was processed). FILING OFFICER please furnish certificate showing any presently effective tax liens as of: □ date of processing □ from ___________________ to date of processing Taxpayer (Last) Name or Business Name First Name Middle Name Mailing Address City State Signature of Requesting Party File Number Zip Code Telephone Number Date and Hour of Filing Amount of Lien Government Authority and Address CERTIFICATE The filing officer certifies that: □ □ □ The above listing is a record of all state and/or federal tax liens which name the requested taxpayer and which are on file in the filing office as of: ______________, 20___ at _______ __ m The attached certificate lists all state and/or federal tax liens which name the requested taxpayer and which are on file in the filing office as of the date and time shown on the certificate. The attached ______ pages are true and exact copies of the tax liens. RETURN REQUESTED INFORMATION TO: (name and address) Date Signature of filing officer Approved by the Secretary of State Rev. 11/2009 American LegalNet, Inc. www.FormsWorkFlow.com