When recorded/filed,

return to:
 
 
 
 
 
 

_______________________________________________________________________

1. Name of Debtor: _______________________________

Address of Debtor: _______________________________

_______________________________

_______________________________

2. Name of Secured Party: _______________________________

Address of Secured Party: _______________________________

_______________________________

_______________________________

3. This Financing Statement covers the following types (or items) of property:

(Describe) ___________________________________________________________

4. (Check here ___ if collateral is crops) The above described crops are growing or are to grown on (Describe real estate) _____________________________________________.

5. (Check here ___ if collateral is goods which are or are to become fixtures, timber to cut, or minerals or the like (including oil and gas) or accounts to be financed at the wellhead or minehead of the well or mine). The legal description of the real estate is: ____________________________________________________________________,

and this Financing Statement is to be filed in the office where a mortgage on the real estate would be recorded. If the debtor does not have an interest of record, the name of the record owner is ___________________________________________.

6. Proceeds and products of collateral are also covered.
 
 

____________________________ ____________________________
Signature of Secured Party                         Signature of Debtor