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201305564 <br /> UCC FINANCING STATEMENTADDENDUM <br /> FOLLOW INSTRUCTIONS(front and back)CAREFULLY <br /> 9.NAME OF FIRST DEBTOR(1a or 1 b)ON RELATED FINANCING STATEMENT <br /> 9a ORGANIZATION'S NAME <br /> GRAND ISLAND FIRST DENTAL,P.C. <br /> OR = <br /> 9b.INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME,SUFFIX' <br /> 10.MISCELLANEOUS: <br /> THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY <br /> 11.ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME-insert only one name(11a or 11b)-do not abbreviate or combine names <br /> 1la.ORGANIZATION'S NAME <br /> OR <br /> 11 b_INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX <br /> Smith Donald G Jr <br /> lic.MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY <br /> 1566 Trumball Terrace Plattsmouth NE 68048 USA <br /> lid.SEE INSTRUCTIONS ADD'L INFO RE I 1 e.TYPE OF ORGANIZATION l It JURISDICTION OF ORGANIZATION 11 g.ORGANIZATIONAL ID#,if any <br /> ORGANIZATION <br /> DEBTOR I Individual I 1 77C INON E <br /> 12. J ADDITIONAL SECURED PARTY'S or I I ASSIGNOR SIP'S NAME-insertonly one name(12a or12b) <br /> 12a.ORGANIZATION'S NAME <br /> OR <br /> 12b_ INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX <br /> 12c_MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY <br /> 13.This FINANCING STATEMENT covers ®timber to be cut or .®as-extracted 16.Additional collateral description: <br /> collateral,or is filed as a ®fixture Sing. <br /> 14.Description of real estate: <br /> OFFICE UNIT "D" IN THE GRAND ISLAND DOCTORS <br /> BUILDING CONDOMINIUM PROPERTY REGIME, LOT ONE <br /> (1), ST. FRANCIS MEDICAL SUBDIVISION IN THE CITY OF <br /> — GRAND ISLAND, HALL COUNTY, NEBRASKA. <br /> 15. Name and address of a RECORD OWNER of above-described real estate(if <br /> Debtor does not have a record interest): <br /> Doug Camplain <br /> 17.Check only if applicable and check only one box_ <br /> Debtor is a n Trust or n Trustee acting with respect to property held in trust or n Decedents Estate <br /> 18.Check only if applicable and check only one box. <br /> ElDebtor is a TRANSMITTING UTILITY <br /> Filed in connection with a Manufactured-Home Transaction <br /> UFiled in connection with a Public-Finance Transaction <br /> FILING OFFICE COPY—UCC FINANCING STATEMENT ADDENDUM(FORM UCC1Ad)(REV.05/21/09) Harland Financial Se,Portland,Solutions <br /> ( �( ) 400 S.W. 6th Avenue,Po Oregon 97204 <br />