Print This Form
Information Sheet and Fees Required
for Filing UCC-1 Financing Statement
List of required Documents:
This Application (please print this form)
Copy of Birth Certificate (both sides)
Other Birth Documents
Copy of Drivers License
Copy of Both Sides of Social Security Cards(s)
Copy of Passport I.D. Page
Copy of UCC Financing Statement (if applicable)
Corporation or Business Information (see below)
Fee for Identity Redemption document preparation and education
service (payment due with this information sheet) $1,997.00
Notes: You are responsible for all State and County filing fees.
We only accept Cash, or Money Orders.
Mailing Address:
Application
Your full name: _______________________________________ Telephone: ________________
Your mailing location:
Street Address_________________________________
City_________________________________________
State________________Zip________County____________
e-mail address: _______________________________________________________________
Social Security #: ________________________________
Birth Certificate #: ___________________________State __________ Birth Date ___________
Date of your 18th Birthday_____________________
Passport # _______________________________________________ Country ________________
Driver License # ______________________________ State __________________
AKA's _____________________________________________
_____________________________________________
Your Maiden Name: __________________Other married name(s): __________________________
Have you already filed a UCC-1? YES NO (circle one) Security Agreement? YES NO (circle one)
First UCC-1 filing # __________________ date filed ______________ State_______________
Second UCC-1 filing #__________________ date filed ______________ State ______________
Treasury Direct Account #________________________ Posted Treasury Registered Account # _________
Fill out all information completely. All information is required, Street Address,
Zip, etc. If you do not have a requested item or number, or cannot get that
information, state in blank, DO NOT HAVE, or CANNOT GET, or other explanation.
ADDITIONAL INFORMATION REQUIRED
IF YOU PARTICIPATE IN AN ENTITY (i.e. Corporation, L.L.C.)
If you have provided services and have agreed to be a "responsible party" for legal fictions, such as trusts, partnerships, firms, or corporations, (ENTITIES) you have the right to protect yourself from potential liability coming from the public side. You can do that through this registration. If you are not participating in ENTITIES you do not need to send in this portion of the form. If you are it is a good thing to do, so you will have this information included in the collateral list.
Address ______________________________________________________________
Is it a corporation or LLC? :_____________________________________________________
County Clerk Record File Number ___________________, Liber _________ Page _________
Title [EX: Trustee] _______________________________________
Date of acceptance of appointment:___________________________________
Name of Creator____________________________________________________