FRAUDULENT UCC FINANCING STATEMENT AFFIDAVIT
Financing Statement must have been filed with the Michigan Secretary of State UCC Office
FOLLOW INSTRUCTIONS (front and back) CAREFULLY
A. Name & Phone (including area code) of Person Filing This Affidavit
B. SEND ACKNOWLEDG
EMENT TO: (Name and Address)
A R 1 2 3 4 5
1. Record to Which This Affidavit Relates: THE
ABOVE SPACE IS FOR FILING OFFICE USE ONLY
1a. RECORD TYPE (Check One) (Found in the upper left hand corner of the
financing statement.)
UCC Financing Statement (UCC1 or UCC1ad)
UCC Financing Statement Amendment (UCC3 or UCC3ad)
1b. MICHIGAN FINANCING STATEMENT FILING NUMBER
(Found in the upper right hand co
rner of the financing statement.
Example: 2009000001-0)
2. Name Of Person Filing This Affidavit - The Record Identified In Item 1 Must Indicate This Person As Debtor.
2a. ORGANI
ZATION’S NAME
OR
2b. INDIVIDUAL’S LAST NAME
FIRST NAME MIDDLE NAME SUFFIX
3. Record is fraudulent. (Provide a statement explaining why the record identified in Item 1 is fraudulent. Attach extra pages if needed.)
4. I certify under penalty of law that the information provided is true, correct, and complete, and I give
notice that the financing statement referenced above is fraudulent.
Affiant Signature: _______________________________________________ Title: ______________ Date: _____________
(The Record Identified In Item 1 Must Indicate This Person As DEBTOR.) (If representing an organization)
Subscribed and sworn to before me on the ___
___
__
day of _____
_______________, ________
_____________________________________________________________________________
(Notary Public Signature)
_____________________________________________________________________________
(Notary Public Printed Name)
Notary Public, State of Michigan, Count
y of _______________
___________________________
My commission expires __________________________ Acting in the County of _____________
An individual who files a materially false or fraudulent UCC Financing Statement Affidavit is
guilty of a felony punishable by imprisonment for not more than 5 years or a $2,500 fine, or
both. [MCL 440.9501a(9)]
A recorded Fraudulent UCC Financing Statement Affidavit terminates the identified financing statement. [MCL 440.9501a(3)]
FORM MIUCC7 03/09
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Instructions for Fraudulent UCC Financing Statement Affidavit (Form MIUCC7)
Please type or legibly print this form. Follow all instructions. Complete the form carefully; mistakes may have
im
portant legal consequences. If you have questions, consult your attorney. The filing office cannot give legal
advice.
Do not insert anything in the open space located on the upper right hand portion of this form; it is reserved for filing
office use only.
This affidavit cannot be filed against a financing statement filed by a regulated financial institution or its
representative. A regulated financial institution is a financial institution subject to regulatory oversight or
examination by a state or federal agency. Regulated financial institution includes, but is not limited to, a bank,
savings bank, savings association, building and loan association, credit union, consumer finance company, industrial
bank, industrial loan company, insurance company, investment company, installment seller, mortgage servicer, sales
finance company, or leasing company.
A. Name & Phone of Person filing This Statement:
If the filing office needs to contact the filer, provide a
name and phone number where the filer may be
reached during normal business hours. Include the
area code.
B. Send Ackn
owledgement To: Enter the name and
address where you want the acknowledgment of
affidavit filing mailed.
1a. Record Type: Check the type of UCC Financing
Statement filed against you as debtor. A copy of the
financing statement was sent with the Debtor
Notification Letter. The record type can be found in
the upper left hand corner of the financing statement.
1b. Michi
gan Financing Statement Filing Number:
To terminate the correct record, the filing office
needs the complete Michigan UCC Financing
Statement filing number. An example of a filing
number is 2009000001-0, found in the upper right
hand corner on the copy of the financing statement
that was sent with the Debtor Notification Letter.
The financing statement must have been filed with
the Michigan Secretary of State UCC Office. This
affidavit must relate to only one financing statement.
Do not enter more than one file number in item 1b.
2. Name of PERSON filing this AFFIDAVIT: The
person filing a Fraudulent UCC Financing Statement
Affidavit must be identified as the debtor on the copy
of the financing statement sent with the Debtor
Notification Letter. Only the named debtor may file.
If the person is an organization, complete 2a. If the
person is an individual, complete 2b.
3. RECORD is fraudulent: Provide a statement
explaining why the record identified in Item 1 is
fraudulent.
4. Certification: Read the certification carefully. If
you are the person named as debtor in the financing
statement sent with the Debtor Notification Letter,
and you agree with the certification statement, sign
and date the Fraudulent UCC Financing Statement
Affidavit. If signing for an organization, include
signer’s title. An unsigned or incomplete
Fraudulent UCC Financing Statement Affidavit
will be rejected.
Mail the completed affidavit to:
Michigan Department of State
UCC Office
PO Box 30197
Lansing, Michigan 48909-7697
03/09