Debtor Request for Certified Statement from Secured Party

TO: ________________________
____________________________
____________________________
____________________________

Attention: __________________

FROM: ______________________
____________________________
____________________________
____________________________

Attention: __________________

Dated: ___________________________

Pursuant to Section 9-208 of the Uniform Security Code, ____________________, as

debtor, requests that the Secured Party, __________________________, provide:

A statement of account, indicating the aggregate amount of unpaid indebtedness as of

_______________________. Approval of the following statement of collateral as
constituting a correct statement of the collateral claimed by Secured Party as of
______________________.

See Exhibit "1" to this form.

The statement above is (check one):

__ Accepted as correct

__ Incorrect, our corrections or response are attached hereto

Dated: ____________________________________

________________________, by:

___________________________________________________
An Authorized Officer

Title: ___________________________________________

_________________________, by:
__________________________________________________
An Authorized Officer

Title: _____________________________________
 Debtor Request for Certified Statement from Secured Party
Review List

This review list is provided to inform you about this document in question and assist you
in its preparation. This is request from a debtor to secured party to certify the exact
amount then due from debtor. This is useful for a variety of reasons, among them for the
benefits of your financial statements and your auditors, should you have them.

1. Make multiple copies. Put one in your financial file, another in the secured
party’s file, and the other in a follow-up file.