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) ASL -1 DEBTOR: 1 NAME: 2 NAME: Notice of Claim of Agricultural Services Lien Pursuant to ORS 87.242 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. (Name of owner(s) of the chattels charged with this lien) MARK ONE If Individual, list last name first. -Business -Business -Individual -Individual MAILING ADDRESS: CITY STATE ZIPCODE CLAIMANT: NAME: MAILING ADDRESS: CITY STATE ZIPCODE PHONE NUMBER LIEN CLAIMANT'S DEMAND (after deducting all credits and offsets): $ THE UNDERSIGNED CLAIMS a lien upon certain chattels, including the following kinds of crops and/or described animals grown in the year upon or currently located at the following described farmland, range, ranch, orchard land: THE LIEN ALSO IS CLAIMED upon the proceeds of the sale of any or all of said crops and animals and to the unborn progeny of said animals, which are in utero on the date of the filing of this claim of lien. This lien is claimed for labor performed, materials supplied and/or services provided by claimant at the request of the owner of said chattels to aid the growing or harvesting of crops and for the raising of livestock upon the land described above. The provided labor, materials and/or services consisted of The amount for which this lien is claimed is a true and bona fide existing debt as of the date of the filing of this notice of claim of lien. The date on which payment was due claimant for said labor, supplies and services was The terms of extended payment (if any) are 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. 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. Please make check payable to "Corporation Division." 440 (01/12) American LegalNet, Inc. www.FormsWorkFlow.com