Secretary of State Post Office Box 136 Jackson, Mississippi 39205-013 Telephone (601) 359-1633 UCC FILING OFFICE SUBSCRIBER REGISTRATION FORM AND AGREEMENT Application by lender/attorney or other authorized searcher for access to restricted electronic UCC Image Vault. Subscriber/Business Name: ___________________________________________________________________ Date: ______/_____/_____ City: _________________________ State: _____________________ Zip Code: ________________Phone: _____________________ Mailing Address: _________________________________________________________________________________________________ Contact Person for Subscriber: ____________________________________ Title: ___________________________________________ Email Address (Required): _________________________________________________________________________________________ The Secretary of State's Office restricts access to the UCC Image Vault as some images contain social security numbers, taxpayer ID numbers and other sensitive personal information. Electronic Access is only granted to organizations or persons having a demonstrated business use or need for the information. The information below is requested to assist us in determining your eligibility for electronic access. Redacted copies of UCC documents are also available by filing a UCC Copy request on UCC Form 11. Subscriber/Type: [ ] Bank [ ] Consumer Finance Company [ ] Attorney [ ] Other_______________________________________ What is your interest in receiving a list of liens? List business purposes: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Government agency or professional group that regulates subscriber, if any: _________________________________________________ Other professional or trade associations' ______________________________________________________________________________ I, the duly authorized representative of the named subscriber, do hereby certify that the information above is true and correct. I understand that this service may provide access to debtors' social security numbers, taxpayer identification numbers and/or sensitive personal information. Subscriber agrees that it will not disclose social security numbers, taxpayer identification numbers and obtained from the UCC Image Vault or any documents contained therein to any person or other organization without the express written consent of the debtor. Subscriber further agrees to indemnify and hold harmless the Secretary of State's Office and the State of Mississippi for any claims arising out of the disclosure social security numbers or taxpayer identification numbers or other sensitive personal information obtained from the Central Filing Registry and which may be attributable to Subscriber or its employees, agents or assigns. Name of Business/Subscriber: _______________________________________________________________________ By: _______________________________________________________________________ SIGNATURE TITLE State of ____________ County of __________ Personally appeared before me, the undersigned authority in and for the said county and state, on this the _____ day of 20___, within my jurisdiction, the within named affiant, who, after being duly sworn, acknowledged that he is the duly authorized representative of the subscriber, and for and on behalf of said subscriber executed the above and foregoing subscription registration form. ____________________________________ Notary Public My Commission expires: ____________________ American LegalNet, Inc. www.FormsWorkFlow.com