The filing of this Statement does not amend any UCC record. This Statement is for informational purposes only.
This document is designed to be a fillable form. Please be sure all pertinent information is completed before printing and mailing the form. Selecting 'Reset' will clear the entire form. PRIVACY ADVISORY: Information such as social security number, date of birth, maiden name, or financial institution account number is NOT required to be included in business entity or Uniform Commercial Code documents filed with the Secretary of State's office. Any information provided on these documents is subject to public viewing.
CORRECTION STATEMENT (Claim Concerning Inaccurate or Wrongfully Filed Record)
FOLLOW INSTRUCTIONS (front and back) CAREFULLY A. NAME & PHONE OF PERSON FILING THIS STATEMENT [optional] B. SEND ACKNOWLEDGMENT TO: (Name and Address)
1. Identification of the RECORD to which this CORRECTION STATEMENT relates.
1a. TYPE OF RECORD 1b. FILE # OF INITIAL FINANCING STATEMENT
THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY
RECORD is inaccurate. Provide the basis for the belief of the person 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. Provide the basis for the belief of the person identified in item 4 that the RECORD identified in item 1 was wrongfully filed.
3. If this CORRECTION STATEMENT relates to a RECORD filed [or recorded] in a filing office described in Section 9-501(a)(1) and this CORRECTION STATEMENT is filed in such a filing
office, provide the date [and time] on which the INITIAL FINANCING STATEMENT identified in item 1b above was filed [or recorded]. 3a. DATE 3b. TIME
4. NAME OF PERSON AUTHORIZING THE FILING OF THIS CORRECTION STATEMENT -- The RECORD identified in item 1 must be indexed under this name.
4a. ORGANIZATION'S NAME
4b. INDIVIDUAL'S LAST NAME
FILING OFFICE COPY -- CORRECTION STATEMENT (FORM UCC5) (REV. 06/09)
Instructions for Correction Statement (Claim Concerning Inaccurate or Wrongfully Filed Record) (Form UCC5)
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 Correction 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 portion of this form; it is reserved for filing office use. When properly completed, send Filing Office Copy to filing office. If you want an acknowledgment, complete item B and, if filing in a filing office that returns an acknowledgment copy furnished by filer, you may also send Acknowledgment Copy; otherwise detach. Always detach Debtor and Secured Party Copies. A. To assist filing offices that might wish to communicate with filer, filer may provide information in item A. This item is optional. B. Complete item B if you want an acknowledgment sent to you. If filing in a filing office that returns an acknowledgment copy furnished by filer, present simultaneously with this form a carbon or other copy of this form for use as an acknowledgment copy.
General -- You must always complete items 1 and 4 and either 2a or 2b. You may also be required to complete item 3. 1a. Indicate type of Record to which this Correction 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., the filing date and/or record number of the Record). 1b. File number: Enter file number of initial financing statement to which the Record that is the object of this Correction Statement relates. Enter only one file number. 2. If this Correction 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, and indicate the manner in which the Record should be amended to cure the inaccuracy. If this Correction Statement is filed based on the filer's belief that the Record identified in item 1 was wrongfully filed, check box 2b and provide the basis for that belief.
If this Correction Statement relates to a Record filed [or recorded] in a filing office described in Section 9-501(a)(1) and this Correction Statement is filed in such a filing office, provide the date [and time] on which the Initial Financing Statement identified in item 1b above was filed [or recorded]. Always enter name of the person who authorized the filing of this Correction Statement. This name must be the same as the name under which the Record is indexed.