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r ii 1 UCC FINANCING STATEMENT FOLLOW INSTRUCTIONS (front and back) CAREFULLY A. NAME & PHONE OF CONTACT AT FILER footionall M C n Y Z ICY D. JCIVU AI.RIVUVVLtUUIVItIV I I U: ovame ana Aaaress) „ r-- �a � r n (n o N c� Heritage Bank N D 1101 12th Street P.O. Box 329 CD Aurora, NE 68818 200306247 THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 1. DEBTOR'S EXACT FULL LEGAL NAME - inr.ert only one l:btor name (1a or 1b) - do not abbreviate or combine names 1a. ORGANIZATION'S NAME OR 1b. INDIVIC SULLIVAN 1c. MAILING ADI FIRST NAME MIDDLE ROGER M CITY STATE rn ORD” r\) CD O O co W � O rC" CT) r\) CD A 11170 S SHADY BEND ROAD I DONIPHAN NE 1 68832 1d. TAX ID #: SSN OR EIN A 1e. TYPE OF ORGANIZATION 1f. JURISDICTION OF ORGANIZATION tg. ORGANIZATIONAL ID #, if any M ((/) r i C-> Cn 2a. ORGANIZATION'S NAME OR `~' o -� 21b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX 2c. MAILING ADDRESS z STATE IPOSTALCODE COUNTRY 2d. TAX ID #: SSN OR EIN - c ORGANIZATION DEBTOR ❑ NONE 3. SECURED PARTY'S NAME (or NAME of TOT /,L ASSIGNEE of ASSIGNOR S /P) -insert only one secured party name (3a or 31b) C:) Cri Heritage Bank 31b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX 3c. MAILING ADDRESS CITY t C.0 t1 _ — 1101 12th Street Aurora NE ti, r M .. m n r: D. JCIVU AI.RIVUVVLtUUIVItIV I I U: ovame ana Aaaress) „ r-- �a � r n (n o N c� Heritage Bank N D 1101 12th Street P.O. Box 329 CD Aurora, NE 68818 200306247 THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 1. DEBTOR'S EXACT FULL LEGAL NAME - inr.ert only one l:btor name (1a or 1b) - do not abbreviate or combine names 1a. ORGANIZATION'S NAME OR 1b. INDIVIC SULLIVAN 1c. MAILING ADI FIRST NAME MIDDLE ROGER M CITY STATE rn ORD” r\) CD O O co W � O rC" CT) r\) CD A 11170 S SHADY BEND ROAD I DONIPHAN NE 1 68832 1d. TAX ID #: SSN OR EIN A 1e. TYPE OF ORGANIZATION 1f. JURISDICTION OF ORGANIZATION tg. ORGANIZATIONAL ID #, if any ORGANIZATION DEBTOR NONE 2. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAMF nsert only one debtor name (2a or 2b) - do not abbreviate or combine names 2a. ORGANIZATION'S NAME OR 21b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX 2c. MAILING ADDRESS CITY STATE IPOSTALCODE COUNTRY 2d. TAX ID #: SSN OR EIN A 2e. TYPE OF ORGANIZATION 2f. JURISDICTION OF ORGANIZATION 2g. ORGANIZATIONAL ID #, if any ORGANIZATION DEBTOR ❑ NONE 3. SECURED PARTY'S NAME (or NAME of TOT /,L ASSIGNEE of ASSIGNOR S /P) -insert only one secured party name (3a or 31b) 3a. ORGANIZATION'S NAME Cri Heritage Bank 31b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX 3c. MAILING ADDRESS CITY STATE POSTAL CODE COUNTRY — 1101 12th Street Aurora NE 68818 4. This FINANCING STATEMENT covers the following collar nal: 5. ALTERNATIVE DESIGNATION [if applicable]: ❑ LESSEE /_ =SSOR ❑ CONSIGNEE /CONSIGNOR ❑ BAILEE /BAILOR ❑ SELLER /BUYER ❑ AG. LIEN ❑ NON -UCC FILING 6. This FINANCING STATEMENT is to be filed [fcr record] ()r recorded) in the REAL . Check to REQUEST SEARCH REPORTJS) on Debtors) ❑ Debtor 1 ❑ Debtor 2 ® ESTATE RECORDS. Attach Addendum [If applicable) [ADDITIONAL FEE] t(optional) ❑ All Debtors . OPTIONAL FILER REFERENCE DATA FILING OFFICE COPY — NATIONAL UCC FINANCING STATEMENT (FORM UCC1) (REV. 07/29/98) Bankers Systems, Inc., St. Cloud, MN Form UCC- 1 -LAZ 5130/2001 SD - e