TN FORM UCC5 (07/13) Business Services Division Tre Hargett, Secretary of State State of Tennessee INSTRUCTIONS Information Statement (TN Form UCC5) Filing Fee: $15.00 A UCC5 Information Statement may be filed using one of the following methods: · E-file: Go to http://tnbear.tn.gov/UCC. Use the online tool to complete the filing and pay the filing fee by credit card, debit card or ACH. When paying by credit card, debit card or ACH, there is a convenience fee that covers the credit card fees and transaction costs incurred by the Business Services Division when accepting online payments. Filers who do not wish to pay the convenience fee to file online may choose the "Print and Mail" option at no additional cost. Print and Mail: Go to http://tnbear.tn.gov/UCC. Use the online tool to complete the filing. Print and mail the application along with the required filing fee to the Secretary of State's office at ATTN: UCC, 312 ROSA L PARKS AVE #6, NASHVILLE TN 37243-1102. Paper submission: A blank form may be obtained by going to http://www.tn.gov/sos/forms/UCC5.pdf, by emailing the Secretary of State at Business.Services@tn.gov, or by calling (615) 741-3276. The application must be hand printed in black ink or computer generated and mailed along with the required filing fee to the Secretary of State's office at ATTN: UCC, 312 ROSA L PARKS AVE #6, NASHVILLE TN 37243-1102. Walk-in: A blank UCC5 form may be obtained in person at the Secretary of State Business Services th Division located on the 6 Floor of the Snodgrass Tower at 312 Rosa L. Parks AVE, Nashville, TN 37243. · · · Please type or laser-print this form. Be sure it is completely legible. Read all Instructions, especially instructions 1a and 1b; correct identification of the initial Record to which this Information Statement relates is crucial. Follow instructions completely. Fill in form very carefully. If you have questions, consult your attorney. Filing office cannot give legal advice. Do not insert anything in the open space in the upper-right portion or in the right hand vertical margin of this form. It is reserved for filing office use. To assist filing offices that might wish to communicate with filer, filer may provide information in items A and B. Complete item C if you want an acknowledgment letter returned to you with your original documents. General - You must always complete items 1 and 4 and either 2a, 2b or 2c . American LegalNet, Inc. www.FormsWorkFlow.com 1a. Initial Financing Statement File number ­ Enter the file number of the initial financing statement (UCC1) to which the Record that is the object of this Information Statement relates. Enter only one file number. 1b. Type of Record ­ Indicate the type of Record to which this Information Statement relates (e.g., Financing Statement or Amendment). You may also insert additional information that you believe will assist in identifying the Record (e.g. Amendment Number). 1c. Date - Enter the date the Record to which this claim relates was filed. 1d. Time - Enter the time the Record to which this claim relates was filed. 2. Check only one box - In no circumstance should more than one box in Item 2 be checked. 2a. RECORD is inaccurate - If this Information Statement is filed based on the filer's belief that the Record identified in item 1 is inaccurate, check box 2a, provide the basis for that belief in item 3, and indicate the manner in which the Record should be amended to cure the inaccuracy. 2b. RECORD was wrongfully filed ­ If this Information Statement is filed based on the belief of the Debtor of Record that the Record identified in item 1 was wrongfully filed, check box 2b and provide the basis for that belief in item 3. 2c. RECORD was filed by a person not entitled to do so ­ If this Information Statement is filed based upon the belief of the Secured Party of Record that the person that filed the record identified in item 1b was not entitled to do so under T.C.A. § 47-9-509(d), check box 2c and provide the basis for that belief in item 3. 3. Basis ­ Use this item to provide the basis for the box checked in item 2. 4. AUTHORIZING PARTY - Enter name of the Debtor/Secured Party who authorized the filing of this Information Statement. This name must be the same as a name under which the Record is indexed. Note: The UCC5 is attached to the record but does not correct any information on the filing. Corrections are filed using the UCC Financing Statement Amendment (TN Form UCC3). Filing Fee · · The filing fee is $15.00. Make check, cashier's check or money order payable to the Tennessee Secretary of State. Cash is only accepted for walk-in filings. Checks, cashier's checks or money orders made out to any payee other than the Tennessee Secretary of State will not be accepted and will result in the rejection of document. American LegalNet, Inc. www.FormsWorkFlow.com CAUTION: This is not an amendment. INFORMATION STATEMENT FOLLOW INSTRUCTIONS CAREFULLY A. NAME & PHONE OF PERSON FILING THIS STATEMENT B. EMAIL CONTACT AT FILER (Optional) C. SEND ACKNOWLEDGMENT TO: (Name and Address) THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 1. Identification of the RECORD to which this INFORMATION STATEMENT relates. 1a. INITIAL FINANCING STATEMENT FILE NUMBER 1c. DATE OF INITIAL FINANCING STATEMENT 1b. TYPE OF RECORD 1d. TIME OF INITIAL FINANCING STATEMENT 2a. RECORD is inaccurate. Enter in item 3 the basis for the belief by the debtor of Record identified in item 4 that the RECORD identified in item 1 is inaccurate and indicate the manner in which the person believes the RECORD should be amended to cure the inaccuracy. RECORD was wrongfully filed. Enter in item 3 the basis for the belief by the Debtor of Record identified in item 4 that the RECORD identified in item 1 was wrongfully filed. RECORD was filed by a person not entitled to do so. Enter in item 3 the basis for the belief by the Secured Party of Record that the person that filed the RECORD identified in item 1 was not entitled to do so under T.C.A. § 47-9-509(d). 2b. 2c. 3. Provide the basis for the claim. 4. NAME OF PERSON AUTHORIZING THE FILING OF THIS INFORMATION STATEMENT - The RECORD identified in item 1 must be indexed under this name. 4a. ORGANIZATION'S NAME OR 4b. INDIVIDUAL'S SURNAME FIRST PERSONAL NAME ADDITIONAL NAME(S) INITIAL(S) SUFFIX NOTE: All information on this form is public record. INFORMATION STATEMENT (TN FORM UCC5) (REV. 07/01/2013) American LegalNet, Inc. www.FormsWorkFlow.com