STATE OF FLORIDA UNIFORM COMMERCIAL CODE
FINANCING STATEMENT FORM
A. NAME & DAYTIME PHONE NUMBER OF CONTACT PERSON
B. Email Address
C. SEND ACKNOWLEDGEMENT TO:
Name
Address
Address
City/State/Zip
THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY
1. DEBTOR’S EXACT FULL LEGAL NAME – INSERT ONLY ONE DEBTOR NAME (1a OR 1b) – Do Not Abbreviate or Combine Names
1.a ORGANIZATION’S NAME
1.b INDIVIDUAL’S SURNAME
FIRST PERSONAL NAME
ADDITIONAL NAME(S)/INITIAL(S)
SUFFIX
1.c MAILING ADDRESS Line One
This space not available.
MAILING ADDRESS Line Two
CITY
STATE
POSTAL CODE
COUNTRY
2. ADDITIONAL DEBTOR’S EXACT FULL LEGAL NAME – INSERT ONLY ONE DEBTOR NAME (2a OR 2b) – Do Not Abbreviate or Combine Names
2.a ORGANIZATION’S NAME
2.b INDIVIDUAL’S SURNAME
FIRST PERSONAL NAME
ADDITIONAL NAME(S)/INITIAL(S)
SUFFIX
2.c MAILING ADDRESS Line One
This space not available.
MAILING ADDRESS Line Two
CITY
STATE
POSTAL CODE
COUNTRY
3. SECURED PARTY’S NAME (or NAME of TOTAL ASSIGNEE of ASSIGNOR S/P) – INSERT ONLY ONE SECURED PARTY (3a OR 3b)
3.a ORGANIZATION’S NAME
3.b INDIVIDUAL’S SURNAME
FIRST PERSONAL NAME
ADDITIONAL NAME(S)/INITIAL(S)
SUFFIX
3.c MAILING ADDRESS Line One
This space not available.
MAILING ADDRESS Line Two
CITY
STATE
POSTAL CODE
COUNTRY
4. This FINANCING STATEMENT covers the following collateral:
5. ALTERNATE DESIGNATION (if applicable) LESSEE/LESSOR CONSIGNEE/CONSIGNOR BAILEE/BAILOR
AG LIEN
NON-UCC FILING SELLER/BUYER
6. Florida DOCUMENTARY STAMP TAX – YOU ARE REQUIRED TO CHECK EXACTLY ONE BOX
All documentary stamps due and payable or to become due and payable pursuant to s. 201.22 F.S., have been paid.
Florida Documentary Stamp Tax is not required.
7. OPTIONAL FILER REFERENCE DATA
STANDARD FORM - FORM UCC-1 (REV.05/2013) Filing Office Copy Approved by the Secretary of State, State of Florida
