Debtor Request for Certified Statement from Secured Party

TO: ________________________
____________________________
____________________________
____________________________

Attention: __________________

FROM: ______________________
____________________________
____________________________
____________________________

Attention: __________________

Dated: ___________________________

Pursuant to Section 9-208 of the Uniform Security Code, ____________________, as debtor, requests that the Secured Party, __________________________, provide:

A statement of account, indicating the aggregate amount of unpaid indebtedness as of _______________________. Approval of the following statement of collateral as constituting a correct statement of the collateral claimed by Secured Party as of ______________________.

See Exhibit “1” to this form.

The statement above is (check one):

__ Accepted as correct

__ Incorrect, our corrections or response are attached hereto

Dated: ____________________________________

________________________, by:

___________________________________________________
An Authorized Officer

Title: ___________________________________________

_________________________, by:

__________________________________________________
An Authorized Officer

Title: _____________________________________