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OR <br />lc. <br />14 <br />OR <br />2c. <br />OR <br />3c. <br />IANCING STATEMENT <br />STRUCTIONS <br />'HONE OF CONTACT AT FILER (optional) <br />(800) 331-3282 Fax: (818) 662 -4141 <br />ONTACT AT FILER (optional) <br />TLS_Glendale_Customer_Service@wOlterSkluwer.com <br />:KNOWLEDGMENT TO: (Name and Address) 25677 - Citizens State <br />en Solutions <br />, .,,. Box 29071 <br />Glendale, CA 91209 -9071 <br />1416 WEST DIVISION ST <br />6500 SW Archer Rd Ste H <br />_ 4. COLLATERAL: This financing statement covers the following collateral: <br />HVAC SYSTEM <br />LOAN AMT: $7000.00 <br />43113208 - 1 <br />NENE <br />FIXTURE <br />File with: Hall County Register of Deeds, NE <br />FILING OFFICE COPY — UCC FINANCING STATEMENT (Form UCC1) (Rev. 04/20/11) <br />3. SECURED PARTY'S NAME (or NAME of ASSIGNEE of ASSIGNOR SECURED PARTY): Provide only one Secured Party name (3a or 3b) <br />-= z - i <br />-c <br />ry <br />1D <br />t ,_.. <br />THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY <br />1. DEBTORS NAME: Provide only one Debtor name (1a or 1 b) (use exact, full name; do not omit, modify, or abbreviate any part of the Debtor's name); if any part of the Individual Debtor's <br />name will not fit in line 1 b, leave all of item 1 blank, check here ❑ and provide the Individual Debtor information in item 10 of the Financing Statement Addendum (Form UCC1Ad) <br />la. ORGANIZATION'S NAME <br />lb. INDIVIDUAL'S SURNAME <br />WYATT <br />MAILING ADDRESS <br />16 WEST DIVISION ST <br />FIRST PERSONAL NAME <br />DARRIN <br />CITY <br />GRAND ISLAND <br />ADDmONAL NAME(S)/INITIAL(S) <br />D <br />STATE POSTAL CODE <br />NE 68801 <br />SUFFIX <br />COUNTRY <br />USA <br />SUFFIX <br />2. DEBTORS NAME: Provide only one Debtor name (2a or 2b) (use exact, full name; do not omit, modify, or abbreviate any part of the Debtor's name); if any part of the Individual Debtor's <br />name will not fit in line 2b, leave all of item 2 blank, check here ❑ and provide the Individual Debtor information in item 10 of the Financing Statement Addendum (Form UCC1Ad) <br />2a. ORGANIZATION'S NAME <br />2b. INDIVIDUAL'S SURNAME <br />WYATT <br />MAILING ADDRESS <br />FIRST PERSONAL NAME <br />MIA <br />CITY <br />GRAND ISLAND <br />ADDITIONAL NAME(S)/INITIAL(S) <br />M <br />STATE <br />NE <br />POSTAL CODE <br />68801 <br />COUNTRY <br />USA <br />3a. ORGANIZATION'S NAME <br />Citizens State Bank <br />3b. INDIVIDUAL'S SURNAME <br />MAILING ADDRESS <br />- FIRST PERSONAL NAME <br />CITY <br />Gainesville <br />ADDITIONAL NAME(S)INITIAL(S) <br />STATE <br />FL <br />POSTAL CODE <br />32608 <br />SUFFIX <br />COUNTRY <br />USA <br />5. Check ok if applicable and check on one box: Collateral is ❑held in a Trust (see UCC1Ad, item 17 and Instructions) ❑being administered by a Decedent's Personal Representative <br />6a. Check m_ki if applicable and check on one box: 6b. Check on if applicable and check oi_LN one box: <br />❑ Public-Finance Transaction ❑ Manufactured -Home Transaction ❑ A Debtor is a Transmitting Utility ❑ Agricultural Lien ❑ Non -UCC Filing <br />7. ALTERNATIVE DESIGNATION (if applicable): ❑ Lessee/Lessor ❑ Consignee /Consignor ❑ Seller/Buyer ❑ Bailee/Bailor 0 Licensee/Licensor <br />8. OPTIONAL FILER REFERENCE DATA: <br />43113208 1143391 <br />Prepared by CT Lien Solutions, P.O. Box 29071, <br />Glendale, CA 91209 -9071 Tel (800) 331-3262 <br />