SSN OR EIN ORGANIZATION

DEBTOR

____________________________________________________________

1f. JURISDICTION OF 1g. ORGANIZATIONAL ID NO.,

ORGANIZATION if any

____________________________________________________[__] NONE

2. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME - insert only one debtor name (2a or 2b) - do not abbreviate or combine names

2a. ORGANIZATION'S NAME

____________________________________________________________

OR 2b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX

____________________________________________________________

2c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY

____________________________________________________________

2d. TAX ID NO. ADD'L INFO. RE 2e. TYPE OF ORGANIZATION

SSN OR EIN ORGANIZATION

DEBTOR

____________________________________________________________

2f. JURISDICTION OF 2g. ORGANIZATIONAL ID NO.,

ORGANIZATION if any

__________________________________________________ [__] NONE

3. SECURED PARTY'S NAME (or name of total assignee of assignor S/P) - insert only one secured party name (3a or 3b)

3a. ORGANIZATION'S NAME

____________________________________________________________