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ANCING STATEMENT <br />FRUCTIONS <br />'HONE OF CONTACT AT FILER (optional) <br />)NTACT AT FILER (optional) <br />(NOWLEDGMENT TO: (Name and Address) <br />,partment, Adams County Bank <br />imith Avenue <br />Kenesaw, Nebraska 68956-0149 <br />L <br />^J <br />rJ <br />N) <br />N <br />C .) <br />j CD <br />CD <br />Fri <br />I <br />r - <br />THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY <br />1. DEBTOR'S NAME: Provide only one Debtor name (1a or 1b) (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 1b, leave all of item 1 blank, check here 0 and provide the Individual Debtor information in item 10 of the Financing Statement Addendum (Form UCC1Ad) <br />OR <br />1 a. ORGANIZATION'S NAME <br />lb. INDIVIDUAL'S SURNAME <br />Kurpgeweit <br />FIRST PERSONAL NAME <br />Chad <br />ADDITIONAL NAME(S)/INITIAL(S) <br />A <br />SUFFIX <br />1c. MAILING ADDRESS <br />15832 S 150TH RD <br />CITY <br />Kenesaw <br />STATE <br />NE <br />POSTAL CODE <br />68956 <br />COUNTRY <br />USA <br />2. DEBTOR'S NAME: Provide only one Debtor name (2a or 2b) (use exact, full name; do not omit, modify, or abbreviate any part of the Debtors 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 0 and provide the Individual Debtor information in item 10 of the Financing Statement Addendum (Form UCC1 Ad) <br />OR <br />2a. ORGANIZATION'S NAME <br />2b. INDIVIDUAL'S SURNAME <br />Kurpgeweit <br />FIRST PERSONAL NAME <br />Jennifer <br />ADDITIONAL NAME(S)/INITIAL(S) <br />SUFFIX <br />2c. MAILING ADDRESS <br />9555 N Constitution Ave • <br />CITY <br />Kenesaw <br />STATE <br />NE <br />POSTAL CODE <br />68956 <br />COUNTRY <br />USA <br />3. SECURED PARTY'S NAME for NAME of ASSIGNEE of ASSIGNOR SECURED PART <br />OR <br />3a. ORGANIZATION'S NAME <br />Adams County Bank <br />3b. INDIVIDUAL'S SURNAME <br />FIRST PERSONAL NAME <br />ADDITIONAL NAME(S)/INITIAL(S) <br />SUFFIX <br />3c. MAILING ADDRESS <br />PO Box 149 401. N Smith Ave <br />CITY <br />Kenesaw <br />STATE <br />NE <br />POSTAL CODE <br />68956-0149 <br />COUNTRY <br />USA <br />coLLArERAL: are financing statement covers the following collateral: 1993 Champion Manufactured Home VIN/Serial No.: 05933526759AB <br />1DVJ1S9V TO <br />5. Check ontt if applicable and check only one box: Collateral is held in a Trust (see UCC) Ad, item 17 and Instructions) being administered by a Decedent's Personal Representative <br />6a. Check only if applicable and check only one box: <br />EiPublic -Finance Transaction NI Manufactured -Home Transaction A Debtor is a Transmitting Utility <br />7. ALTERNATIVE DESIGNATION (if applicable): I 1 Lessee/Lessor <br />8. OPTIONAL FILER REFERENCE DATA: <br />6b. Check only if applicable and check ons one box: <br />Agricultural Lien ,' Non -UCC Filing <br />r1 Consignee/Consignor n Seller/Buyer Bailee/Bailor <br />❑ Licensee/Licensor <br />FILING OFFICE COPY — UCC FINANCING STATEMENT (Form UCC1) (Rev. 04/20/11) Wolters Kluwer Financial Services UCC -10713 1/1/2017 <br />