PPRFSVER ( 1.00.44 )
Printed on: 12/12/07 11:17 Page 1 of 2
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12 December 2007 Ref: EVSRPRFS/7226676/PPSR
Debtor PIN: Date of Expiry: 23033433 12−Dec−2012 11:17:08
VERIFICATION STATEMENT Financing Statement Registration No: A UNIQUE REGISTRATION NUMBER
Status: Time of Registration: DEBTOR First Name: Middle Names: Last Name: Date of Birth: DEBTORS FULL NAME 29−Feb−1968 Email Address: Fax: Contact Address: Suburb: City/Town: Country: CITY OR TOWN New Zealand (MANDATORY) THE DEBTOR’S ADDRESS Mailing Address: Suburb: City/Town: Country: Debtor Reference: (OPTIONAL) PROVIDED BY THE SPG GENERALLY TO HELP IDENTIFY THE DEBTOR − COULD BE A CUSTOMER NUMBER OR MAYBE AN INVOICE NUMBER OPTIONAL.EMAIL@DEBTORS.ADDRESS.N (OPTIONAL) (OPTIONAL) ONLY IF DIFFERENT FROM THE CONTACT ADDRESS GIVEN CITY OR TOWN New Zealand Registered 12−Dec−2007 11:17:08
Contact Telephone No: (OPTIONAL)
COLLATERAL Collateral Type: Description: Item Description: Colour: Identifying Number: Goods − Other The Secured Party will provide a description of the collateral here. It would normally be enough to easily identify the goods, but wouldn’t contain any financial information (e.g. an item’s value). (OPTIONAL) Useful if there is more than one item of collateral to be described under the Goods − Other description. (OPTIONAL) COLOUR Make: (OPTIONAL) ITEM MAKE (OPTIONAL) SERIAL NUMBER OR Model: (OPTIONAL) ITEM MODEL SIMILAR IDENTIFYING NUMBER
EMAIL: registrar@ppsr.govt.nz
WEBSITE: www.ppsr.govt.nz
Level 18, 135 Albert Street, ASB CENTRE, Private Bag 92061, AUCKLAND MAIL CENTRE NZ FREECALL: (0508) 777−746 Fax: +64 9 916−4559
PPRFSVER ( 1.00.44 )
Printed on: 12/12/07 11:17 Page 2 of 2
SECURED PARTY Organisation Name: Contact Telephone No: Contact Address: Suburb: City/Town: Country: CITY OR TOWN New Zealand SPG CONTACT ADDRESS DEMONSTRATION SECURED PARTY GROUP Email Address: Fax: Mailing Address: Suburb: City/Town: Country: Email Address: Fax: Contact Telephone: Mailing Address: Suburb: City/Town: Country: info@ppsr.govt.nz +64(3)9622700 SPG MAILING ADDRESS IF DIFFERENT FROM THE CONTACT ADDRESS CITY OR TOWN New Zealand info@ppsr.govt.nz +64(3)9622700 CONTACT PERSON’S MAILING ADDRESS IF DIFFERENT FROM THE CONTACT ADDRESS CITY OR TOWN New Zealand
Person Acting on Behalf of: First Name: Last Name: Contact Address: Suburb: City/Town: Country: CITY OR TOWN New Zealand THE MANAGER CONTACT PERSON’S ADDRESS
EMAIL: registrar@ppsr.govt.nz
WEBSITE: www.ppsr.govt.nz
Level 18, 135 Albert Street, ASB CENTRE, Private Bag 92061, AUCKLAND MAIL CENTRE NZ FREECALL: (0508) 777−746 Fax: +64 9 916−4559