Montana Form M-1 Rev. 05/10 Secured Party Addition Form Return to: Montana Department of Revenue Liquor Licensing PO Box 1712 Helena, MT 59624-1712 Instructions: Please type or print this form. Complete all applicable portions of the form, all parties must sign. If being submitted for a new license or a license to be transferred, the proposed licensee(s)/applicant(s) must be listed as borrower/debtor. Send a $20.00 fee for the addition (This fee includes the termination fee). If signing on behalf of a corporation, bank, etc. please indicate the office held. Copies of any and all documents supporting the security interest must accompany this form, including but not limited to the security agreement and promissory note. See ARM 42.12.205 for reference Borrower/Debtor(s) Name and Address: Lender/Secured Party(ies) Name and Address: License No. _________________________ Trade Name of Business: ___________________ Loan No. Location Address: _________________________ _________________________ The undersigned hereby request that the person(s) named above be endorsed on the face of the license as a secured party. Dated this ___________day of ________________, 20________ Signature(s) of Borrower/Debtor(s): (Please type or print name after each signature) _____________________________________ Signature Date _____________________________________ Signature Date Signature(s) of Lender/Secured Party(ies): (Please type or print name after each signature) _________________________________ Signature Title _________________________________ Signature Title 512 American LegalNet, Inc. www.FormsWorkFlow.com