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201305564 <br /> UCC FINANCING STATEMENTADDENDUM <br /> FOLLOW INSTRUCTIONS(front and back)CAREFULLY <br /> 9.NAME OF FIRST DEBTOR(la or 1b)ON RELATED FINANCING STATEMENT <br /> 9a ORGANIZATION'S NAME <br /> GRAND ISLAND FIRST DENTAL,P.C. <br /> OR <br /> 9b.INDIVIDUALS 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(11 a or 11 b)-do not abbreviate or combine names <br /> 11a ORGANIZATION'S NAME <br /> OR <br /> 11 b.INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX <br /> Smith Don <br /> 11c.MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY <br /> 1566 Trumball Terrace Plattsmouth NE 68048 USA <br /> lid.SEE INSTRUCTIONS ADD`L INFO RE 111 e_TYPE OF ORGANIZATION 11f_JURISDICTION OF ORGANIZATION 11g.ORGANIZATIONAL ID#,if any <br /> ORGANIZATION Individual <br /> DEBTOR 1 4AINONE <br /> 12. I ADDITIONAL SECURED PARTY'S or I I ASSIGNOR SIP'S NAME--insert only one name(12a or 12b) <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 out or ® 15.Additional collateral description: <br /> ption: <br /> collateral=or is filed as a El fixture filing_ <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 11 Trust or fl Trustee acting with respect to property held in trust or fl Decedents Estate <br /> 18.Check only if applicable and check only one box. <br /> Debtor is a TRANSMITTING UTILITY <br /> ®Filed in connection with a Manufactured-Home Transaction <br /> 0 Filed in connection with a Public-Finance Transaction <br /> FILING OFFICE COPY—UCC FINANCING STATEMENT ADDENDUM(FORM UCC1Ad)(REV. 05/21/09) Harland Financial Ave Solutions e,Portland, <br /> ( )( � 400 S.W. 6th Avenue,Po Oregon 97204 <br />