The filing of this statement of claim does not affect the effectiveness of an initial financing statement or other filed record. STATEMENT OF CLAIM FOLLOW INSTRUCTIONS (front and back) CAREFULLY A. NAME & PHONE OF PERSON FILING THIS STATEMENT [optional] B. SEND ACKNOWLEDGMENT TO: (Name and Address) This document is designed to be a fillable form. Please be sure all pertinent information is completed before printing and mailing the form. Selecting 'Reset' will clear the entire form. PRIVACY ADVISORY: Information such as social security number, date of birth, maiden name, or financial institution account number is NOT required to be included in business entity or Uniform Commercial Code documents filed with the Secretary of State’s office. Any information provided on these documents is subject to public viewing. Print Reset THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 1. Identification of the RECORD to which this STATEMENT OF CLAIM relates. 1a. INITIAL FINANCING STATEMENT FILE NUMBER 2a. 1b. RECORD INFORMATION TO WHICH THIS STATEMENT OF CLAIM RELATES RECORD is inaccurate. Provide the basis for the belief of the person identified in item 4 that the RECORD identified in item 1 is inaccurate and indicate the manner in which the person believes the RECORD should be amended to cure the inaccuracy. 2b. RECORD was wrongfully filed. Provide the basis for the belief of the person identified in item 4 that the RECORD identified in item 1 was wrongfully filed. 3. If this STATEMENT OF CLAIM relates to a RECORD filed [or recorded] in a filing office described in Section 9-501(a)(1) and this STATEMENT OF CLAIM is filed in such a filing office, provide the date [and time] on which the INITIAL FINANCING STATEMENT identified in item 1a above was filed [or recorded]. 3a. DATE 3b. TIME 4. NAME OF PERSON AUTHORIZING THE FILING OF THIS STATEMENT OF CLAIM — The RECORD identified in item 1 must be indexed under this name. 4a. ORGANIZATION'S NAME OR 4b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX International Association of Commercial Administrators (IACA) FILING OFFICE COPY — STATEMENT OF CLAIM (FORM UCC5) (REV. 01/01/10) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Statement of Claim (Form UCC5) Please type or laser-print this form. Be sure it is completely legible. Read all Instructions, especially Instructions 1a and 1b; correct identification of the initial Record to which this Statement of Claim relates is crucial. Follow Instructions completely. Fill in form very carefully. If you have questions, consult your attorney. Filing office cannot give legal advice. Do not insert anything in the open space in the upper portion of this form; it is reserved for filing office use. When properly completed, send Filing Office Copy to filing office. Always detach Debtor and Secured Party Copies. ITEM INSTRUCTIONS A. To assist filing offices that might wish to communicate with filer, filer may provide information in item A. This item is optional. B. Complete item B if you want an acknowledgment sent to you. If filing in a filing office that returns an acknowledgment copy furnished by filer, present simultaneously with this form a carbon or other copy of this form for use as an acknowledgment copy. General — You must always complete items 1 and 4 and either 2a or 2b. You may also be required to complete item 3. 1a. File number: Enter file number of initial financing statement to which the Record that is the object of this Statement of Claim relates. Enter only one file number. 1b. Enter record information to which this Statement of Claim relates. Indicate the type of Record to which this Statement of Claim relates (e.g., Financing Statement or Amendment) or you may also insert additional information that you believe will assist in identifying the Record (e.g., the Record file number or the filing date of the Record). 2a. If this Statement of Claim is filed based on the filer's belief that the Record identified in item 1 is inaccurate, check box 2a, provide the basis for that belief, and indicate the manner in which the Record should be amended to cure the inaccuracy. 2b. If this Statement of Claim is filed based on the filer's belief that the Record identified in item 1 was wrongfully filed, check box 2b and provide the basis for that belief. 3. If this Statement of Claim relates to a Record filed [or recorded] in a filing office described in Section 9-501(a)(1) and this Statement of Claim is filed in such a filing office, provide the date [and time] on which the initial financing statement identified in item 1a above was filed [or recorded]. 4. Always enter name of the person who authorized the filing of this Statement of Claim. This name must be the same as the name under which the Record is indexed. American LegalNet, Inc. www.FormsWorkFlow.com