Form UCC Uniform Commercial Code Act
Affidavit of Compliance for Service
Secretary of State
Department of Business Services
on Secretary of State
501 S. Second St., Rm. 350W SUBMIT IN DUPLICATE
Springfield, IL 62756 Type or Print Clearly.
www.cyberdriveillinois.com This space for use by Secretary of State.
Payment must be made by certified
check, cashierʼs check, money order, Date:
Illinois attorneyʼs check or Illinois
C.P.A.ʼs check. This space for use by Secretary of State.
1. Affiant Name: ______________________________________________________________
2. Financing Statement/Amendment Number Listing Affiant as a Debtor:
3. I hereby affirm my reasonable belief that the aforementioned filing (initial each):
a. _____ is not authorized or permitted under Section 9-509, 9-708, or 9-808 of the Uniform
Commercial Code (810 ILCS 5);
b. _____ is not related to a valid existing or potential commercial or financial transaction, an
existing agricultural or other lien, or a judgment of a court of competent jurisdiction; and
c. _____ is filed with intent to harass or defraud me and/or other person(s).
4. The undersigned affirms, under penalties of perjury, that the facts stated herein are true,
correct and complete.
______________________________________ ________________ ________________
Signature of Affiant Month & Day Year
Affiant Contact Information (please type or print clearly):
City State ZIP
Printed by authority of the State of Illinois. September 2012 — 500 — UCC 57
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