#4150
@001 Please enter the name of the Secured Party:
@415 Please enter 1st line, address of Secured Party:
@416 Please enter the 2nd line of address of Secured Party:
@417 Please enter the City, State, Zip Code of Secured Party:
@418 Please enter the name of officer or department:
@002 Please enter the name of the Debtor:
@419 Please enter 1st line, address of Debtor:
@420 Please enter the 2nd line of address of Debtor:
@421 Please enter the City, State, Zip Code of Debtor: 
@423 Please enter the name of the officer or department:
@424 Please enter the date for which a statement is requested:
#4151 Is statement of account balance requested?
#4152 Is statement of collateral requested?
#4153
#4154
#end control section
#4150
/* Para. 4150: Secured party statement, Request */
      REQUEST FOR STATEMENT OF ACCOUNT, LIST OF COLLATERAL

TO: @001

@415

@416

@417


Attention: @418


FROM: @002

@419

@420

@421


Attention: @423



Dated: ___________________________


Pursuant to Section 9-208 of the Uniform Security Code, @002, as 
debtor, requests that the Secured Party, @001, provide:
#4151
/* Para. 4151: Statement of account, collateral */


A statement of account, indicating the aggregate amount of unpaid 
indebtedness as of @424.
#4152
/* Para. 4152: Statement of collateral */

Approval of the following statement of collateral as constituting 
a correct statement of the collateral claimed by Secured Party:
as of @424


See Exhibit "1" to this form
#4153
/* Para. 4153: Approval form*/


The statement above is (check one):








________________ Accepted as correct



_______________ Incorrect, our corrections or response are 
attached hereto



Dated: ____________________________________






@002, by:






___________________________________________________

An Authorized Officer



Title: ___________________________________________                               
#4154
/* Para. 4154: Signature of the debtor */


@001 by:





__________________________________________________

An Authorized Officer                                                            


Title: _____________________________________