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UCC FINANCING STATEMENT ADDENDUM <br />FOLLOW INSTRUCTIONS <br />9. <br />AME OF FIRST DEBTOR: Same as line la or 1b on Financing Statement; if line lb was left blank <br />because Individual Debtor name did not fit, check here ❑ <br />OR <br />9a. ORGANIZATION'S NAME <br />9b. INDIVIDUAL'S SURNAME <br />DOCKHORN <br />FIRST PERSONAL NAME <br />JACQUELINE <br />ADDITIONAL NAME(S)/INITIAL(S) <br />FISHER <br />SUFFIX <br />202004351 <br />THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY <br />10. DEBTOR'S NAME: Provide (10a or 10b) only o g additional Debtor name or Debtor name that did not fit in line lb or 2b of the Financing Statement (Form UCC1) (use exact, full name; <br />do not omit, modify, or abbreviate any part of the Debtor's name) and enter the mailing address in line 10c <br />10a. ORGANIZATIONS NAME <br />OR <br />10b. INDIVIDUAL'S SURNAME <br />INDIVIDUAL'S FIRST PERSONAL NAME <br />INDIVIDUAL'S ADDITIONAL NAME(S)/INITIAL(S) <br />SUFFIX <br />10c. MAILING ADDRESS <br />CITY <br />STATE <br />POSTAL CODE <br />COUNTRY <br />11. <br />OR <br />❑ ADDITIONAL SECURED PARTY'S NAME <br />pi <br />• <br />ASSIGNOR SECURED PARTY'S NAME: Provide only gpg name (11a or 11b) <br />11 a. ORGANIZATION'S NAME <br />11b. INDIVIDUAL'S SURNAME <br />FIRST PERSONAL NAME <br />ADDITIONAL NAME(S)/INITIAL(S) <br />SUFFIX <br />11c. MAILING ADDRESS <br />CITY <br />STATE <br />POSTAL CODE <br />COUNTRY <br />12. ADDITIONAL SPACE FOR ITEM 4 (Collateral): <br />2703 W JOHN <br />GRAND ISLAND, NE 68803 THIS FILING IS MADE FOR NOTICE PURPOSES ONLY. THE DEBTOR HAS NO <br />OWNERSHIP RIGHTS IN THE COLLATERAL. <br />- THE DEBTOR IS LEASING THE COLLATERAL. <br />13. m This FINANCING STATEMENT is to be filed [for record] (or recorded) in the <br />REAL ESTATE RECORDS (if applicable) <br />14. This FINANCING STATEMENT: <br />❑ covers timber to be cut covers as -extracted collateral VI is filed as a fixture filing <br />15. Name and address of a RECORD OWNER of real estate described in item 16 <br />JACQUELINEhFISHERnDrOCKHORN <br />2703 W JOHN ST <br />• GRAND ISLAND, NE 68803 <br />16. Description of real estate: <br />A PARCEL OF LAND LOCATED IN THE STATE OF NE, COUNTY <br />OF HALL, WITH A SITUS ADDRESS OF 2703 W JOHN ST, <br />GRAND ISLAND NE 68803-5710 CO24 CURRENTLY OWNED BY <br />FISHER DOCKHORN JACQUELINE HAVING A TAX ASSESSOR <br />NUMBER OF 400136228 AND BEINGTHE SAME PROPERTY <br />MORE FULLY DESCRIBED AS GLADSTONE PLACE LT 1 BLK 7 <br />17. MISCELLANEOUS: <br />FILING OFFICE COPY— UCC FINANCING STATEMENT ADDENDUM (Form UCC1Ad) (Rev. 04/20/11) <br />