Free Mail to - Colorado

Mail to: Secretary of State UCC Section 1700 Broadway, Suite 200 Denver, CO 80290

For Office Use Only Please include a typed self-addressed envelope. MUST BE TYPED FILING FEE: $15.00 MUST SUBMIT TWO COPIES HOSPITAL LIEN FILING FORM You must check one of the following boxes that describes the type of document you are filing: Original Hospital Lien Amendment to Original Hospital Lien Termination of Original Hospital Lien If you check the "Amendment" or "Termination" box, you MUST include the original filing number on file with the Secretary of State on the following line: Original Filing Number Date of Injury _____________________ _____________________

Injured Person / Responsible Party _________________________________________________ Address _________________________________________________
(Street) (Apt. #)

_________________________________________________
(City) (State) (Zip Code)

Person Allegedly Liable for Injuries _________________________________________________ Hospital Address _________________________________________________ _________________________________________________
(Street) (Apt. #)

_________________________________________________
(City) (State) (Zip Code)

Signature of Filer Date

_____________________ _____________________

Form054

Rev.8/22/2008