FINANCING STATEMENT FOR REAL ESTATE AND UCC FILING/UCC-1A SECRETARY OF STATE SFN 17832 (02-2014) Type or print legibly. Carefully follow instructions on page 2. Please read instructions on page 2 before completing. 1a. Contact Name: (optional) 1b. Send Acknowledgement to: (Name and Address) Telephone Number Debtor Information (2 and 3): Provide only one debtor name (a or b). If an organization, provide the name as registered on the organization's public record, or if not registered, in the correct legal name. If an individual, provide the name as it appears on the individual's driver's license or identity card issued by this state, or if no license or identity card has been issued, provide the surname and first personal name. Do not omit, modify or abbreviate any part of the debtor's name. 2. Debtor's Name: 2a. Organization's Name THIS SPACE IS RESERVED FOR OFFICE USE ONLY OR 2b. Individual's Last Name First Name City State Middle Name Postal Code Suffix Country 2c. Mailing Address 3. Additional Debtor's Name: 3a. Organization's Name OR 3b. Individual's Last Name First Name City State Middle Name Postal Code Suffix Country 3c. Mailing Address 4. Secured Party's Name (or Name of Total Assignee of Assignor Secured Party): Provide only one secured party name (4a or 4b) 4a. Organization's Name OR 4b. Individual's Last Name First Name City 6. Description of Collateral: State Middle Name Postal Code Suffix 4c. Mailing Address 5. This financing statement covers the following types (or items) of property: (Check applicable box(es)) Fixtures Goods to become fixtures Timber Minerals or the like (including oil and gas) Accounts resulting from sale of minerals 7. Products of collateral are also covered: Yes at wellhead or minehead. 8. Legal Description of Property: (This financing statement is to be filed for record in the real estate records.) No 9. Name of Record Owner: (If the debtor does not have an interest of record) American LegalNet, Inc. www.FormsWorkFlow.com SFN 17832 (02-2014) FINANCING STATEMENT FOR REAL ESTATE AND UCC FILING/UCC-1A INSTRUCTIONS FEES: $28...Recording Fee and UCC-1A Filing Fee/UCC Termination $33...Recording Fee and Non-standard UCC-1A Filing Fee/UCC Termination $13...Satisfaction Fee $3...Per additional attached page (typed or legibly printed) $10...Margin Fee (If instrument does not contain 1 inch top, bottom or side margin on each page) FILING OFFICE: Submit the original document to the County Recorder's office in the county where recording in the real estate records is required. The UCC filing must be filed with the same County Recorder. DO NOT FILE THIS FORM WITH THE SECRETARY OF STATE. ACCURACY: Before filing, carefully review for accuracy. The statement must be filed as presented to the filing office. Any inaccuracies can only be corrected by filing a UCC-3A Amendment. ADDENDUMS: If the space provided on the form is inadequate, each additional page. ACKNOWLEDGEMENT COPY: An acknowledgement will be sent to the filer at the address provided in number 1b. WHEN TO USE THE UCC-1A: When the collateral is timber to be cut or is minerals or the like (including oil and gas), or accounts subject to Subsection 5 of Section 41-0903 of the North Dakota Century Code (N.D.C.C.) or when the financing statement is filed as a fixture filing (N.D.C.C. § 41-09-34) and the collateral is goods which are or are to become fixtures, then use the UCC-1A and file in the office where a mortgage on the real estate would be filed or recorded. This form will serve for both UCC-1 filing and real estate recording. The following instructions relate to the respective number on this form. 1. CONTACT/ADDRESS FOR ACKNOWLEDGEMENT: a. To assist the filing office that may need to contact the filer, provide the name and telephone number of the filer (optional). b. Provide the mailing address where the filing office will send the acknowledgement copy after filing. 2. DEBTOR NAME: As required by N.D.C.C., Section 41-09-74 (as effective after June 30, 2013), provide only one debtor name in number 2; an organization's name (2a) or an individual's name (2b). If an organization, provide the name as registered on the organization's public record, or if not registered, in the correct legal name. If an individual, provide the name as it appears on the individual's driver's license or identity card issued by this state, or if no license or identity card has been issued, provide the surname and first personal name. Do not omit, modify, or abbreviate any part of the debtor's name. Provide the complete mailing address of the debtor (2c). 3. Follow instructions in number 2 if a second debtor is added. 4. SECURED PARTY NAME: Provide only one secured party name in number 4: an organization's name (4a) or an individual's name (4b) and a complete mailing address (4c). 5. Check the appropriate boxes to identify the collateral. 6. Describe the collateral. 7. Check the appropriate box to indicate if products of the collateral are also covered. 8. Provide the legal description of the property for recording in real estate records. 9. If the debtor does not have an interest of record in the real estate, provide the name of a record owner. American LegalNet, Inc. www.FormsWorkFlow.com