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<br />... <br /> <br />UCC FINANCING S1 A TEMENT ADDENDUM <br />FOLLOW INSTRUCTIONS (front and back) CAREFULLY <br />9. NAME OF FIRST DEBTOR (la or lb) ON RELATED FINANCING STATEMENT 200512725 <br /> 9a. ORGANIZATION'S NAME <br />OR BOSSELMAN, INC. <br /> 9b. INDIVIDUAL'S LAST NAME I FIRST NAME IMIDDLE NAME,SUFFIX <br />10. MISCELLANEOUS; <br /> THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY <br /> <br />11. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME- insert only = nama (11e or 11b) - do not abbreviate or combine namas <br /> <br /> 11a. ORGANIZATION'S NAME <br />OR 11 b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX <br />11c. MAILING ADDRESS CITY STATE I POSTAL CODE COUNTRY <br />11d. TAXID#: SSN OR EIN IADD'L INFO RE 111e. TYPE OF ORGANIZATION 111. JURISDICTION OF ORGANIZATION 11g. ORGANIZATIONAL 10 #. ~ any <br /> ORGANIZATION I n NONE <br /> DEBTOR I I <br />12. J ADDITIONAL SECURED PARTY'S Q[ I I ASSIGNOR SIP'S NAME -Insert only ona name (12a or 12b) <br /> 12a. ORGANIZATION'S NAME <br />OR FIRST NAME MIDDLE NAME <br /> 12b. INDIVIDUAL'S LAST NAME SUFFIX <br />12c. MAILING ADDRESS CITY STATE I POSTAL CODE COUNTRY <br />13. This FINANCING STATEMENT covers uU timber to be cut or U as-<lxtrac1ad 16. Additional collataral deScription: <br /> collataral, or is filed as a jgJ fixture filing. <br />14. Dascription of real estata: <br />3335 West Wood River Rd. <br />Grand Island, NE 68801 <br />That part of Bosserman Travel Center: <br />Lot One (1), Block One (1), Bosselville Subdivision, <br />Hall County, Nebraska <br />15. Name and eddress of e RECORD DINNER of above-<lescrlbed real astata <br /> (~ Debtor does not have a record intarast); <br /> 17. Check QJlli W applicable and check QJlli one box. <br /> Debtor is a 0 Trust or 0 Trustee ac1ing with raspac1to property hald In trust or n Decadent's Estate <br /> 18. Check 2!!!Y ~ applicable and check 2!!!Y One box. <br /> - Debtor is e TRANSMITTING UTILITY <br /> - Filed In connection with e Manufac1ured-Home Transac1ion - effec1iva 30 years <br /> Filed in connection w~h a PUblic-Financa Transaction - effective 30 years <br /> <br />ACKNOWLEDGMENT COPY - UCC FINANCING STATEMENT ADDENDUM (FORM UCC1Ad) (REV. OS/22/02) <br /> <br />INFO.PRO www.infoproforms.com (B0Q-655-2021) <br />