NEBRASKA AGRICULTURAL PRODUCTION INPUT LIEN API For Filing Office Use Only NOTIFICATION STATEMENT This Statement must be typed or printed. Illegible Statements will be returned without filing. This form to be filed with the NE Secretary of State beginning July 1, 1999. 1. DEBTOR -- 2. DEBTOR if Individual Name (Last, First, Middle Initial) Residential Address -- if Entity Name Address City State Zip Code Soc. Sec. No. or Fed. Tax I.D. No. City State Zip Code Soc. Sec. No. or Fed. Tax I.D. No. 3. ADDITIONAL DEBTOR 4. SUPPLIER (Secured Party) 5. LENDER (Attach additional) Name Name Name Address Address Address City State Soc. Sec. No. or Fed. Tax I.D. No. Zip Code City State Zip Code Soc. Sec. No. or Fed. Tax I.D. No. City 7. Date(s) of Transaction 8. Retail Cost or Anticipated Costs of the Agricultural Input 10. Livestock Lien Owner (If individual, list LN, FN, MI) Owner (If individual, list LN, FN, MI) Owner (Residential) Address Zip Code Soc. Sec. No. or Fed. Tax I.D. No. 6. This Notification Statement Covers the following described agricultural input and all products or proceeds of the crops or livestock covered by the lien. 9. Crop Lien State Owner (Residential) Address $ City Description of Real Estate for Crops State Zip Code City 11. Signature of Debtor(s) below State Zip Code Location and Description of Livestock 12. Signature of Supplier(s) below By NOTICE TO LENDER: You are hereby notified of the above described Agricultural Production Input Lien. You have 15 calendar days from the date of receipt of this notice in which to respond with either a letter of commitment for part or all of the amount in this lien notification statement or a written refusal to issue a letter of commitment. If the letter of commitment is for only part of the amount or a written refusal to issue a letter of commitment, then a copy of the partial commitment or written refusal shall be sent to the person to whom the ag production input was furnished or is to be furnished. If you respond in any manner described in said time, your rights under any prior perfected lien under the Uniform Commercial Code shall retain its priority. If you do not respond to the supplier within 15 calendar days, an Agricultural Production Input Lien corresponding to this lien notification statement has priority over any security interest statement you might have in livestock and in the crops or their proceeds for the lesser of (1) the amount stated in the lien notification statement; or (2) the unpaid retail cost of the agricultural production input identified in the lien notification statement. INSTRUCTIONS If a response is not received from the lender within 15 calendar days, this statement is then to be filed with the Secretary of State within 3 months after the last date that the agricultural production input was furnished. If the space provided for any items on this form is inadequate, the item(s) may be continued on additional 8 ½ inch by 11 inch sheets of paper. When the form is completed and signed you should remove the second page and send it to the lender by certified mail or another verifiable method. If there are multiple lenders you should photocopy that page and mail it to all of them. Mark the envelope “IMPORTANT - LEGAL NOTICE”. In order to perfect the agricultural production input lien, the lien must attach and the supplier entitled to the lien must file the lien notification statement with the Secretary of State - UCC Division, P O Box 95104, Lincoln, NE 68509. Lienholder will receive an acknowledgment from the Secretary of State. 1999 NEBRASKA COOPERATIVE COUNCIL 134 SOUTH 13TH STREET SUITE 314 LINCOLN NE 68508-1901 (402) 475-6555 SECRETARY OF STATE - WHITE COPY COPIES TO EACH OF THE FOLLOWING: LENDER - GREEN COPY SUPPLIER - CANARY COPY American LegalNet, Inc. www.USCourtForms.com DEBTOR - PINK COPY Approved by the Secretary of State (REVISED 4-99)