Secretary of State Corporation Division - UCC 255 Capitol St. NE, Ste. 151 Salem, OR 97310-1327 Phone: (503) 986-2200 Fax: (503) 373-1166 FilingInOregon.com (Reserved for Filing Officer Use) APL -1 DEBTOR Notice of Agricultural Produce Lien Pursuant to ORS 87.710 In keeping with ORS 192.410-192.595, the information on the application is public record. We must release this information to all parties upon request and it may be posted on our website. Please Type or Print Legibly in Black Ink. Attach Additional Sheet if Necessary. CHECK ONE If Individual, list last name first. PURCHASER: NAME 1 NAME 2 -Business -Business -Individual -Individual ADDRESS CITY STATE ZIPCODE PRODUCER: NAME ADDRESS CITY STATE ZIPCODE STATEMENT AMOUNT OF PRODUCER'S DEMAND (after Deducting All Credits and Offsets) : $ DESCRIPTION OF PRODUCE DELIVERED OR TRANSFERRED BY: DATE PAYMENT ORIGINALLY DUE: I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Signature of Claimant or Representative: Printed Name: RETURN TO (Please Type or Print within the box): FEES Required Processing Fee $15.00 Processing Fees are nonrefundable. Please make check payable to "Corporation Division." NOTE: Fees may be paid with VISA or MasterCard. The card number and expiration date should be submitted on a separate sheet for your protection. 430 (01/12) American LegalNet, Inc. www.FormsWorkFlow.com