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UCC Fprm •1lja - ilsortter from: tluttan Forma 1t10., Orlettdo. Fla. 52lOb
1970 -Sutton Formf Intr. - p06) Egb-J6~1
STATE Of FLORIDA
UNIFORM COMMERCIAL CODE -FINANCING STATEMENT
(Use ONLY for recording in offices of Clerks of the Circuit Court -NOT for filing with the Secretary of State.)
INSTRUCTIONS:
1. TYPE All INFORMATION, using a typewriter having a gooci'tibbon, AND ACCURATELY TYPE THE NAME BELOW EACH
SIGNATURE.
2. Be sure to fill in All numbered apace: which are applicable.
3. If any space is not Isrge enough, type therein "See attad~ed sheet(sY'. (The size should be 8'h" x 14" or smaller.)
4. If collateral is farm products, or goods which are or are to become fixtures, type in space No. 4 a description of the real
estata which "reasonably identifies what is described", and give name of record owner.
5. SEND ORIGINAL OF EACH PAGE TO THE CLERK'S OFFICE to be recorded and returned. IF you are paying an additional fee
for having recording information noted on a copy, also send a legible carbon copy of the first page.
6. BE SURE TO CHECK ONE OF THE TWO STATEMENTS UNDER NO.B BELOW.
This FINANCENG STATEMENT is presented to a Clerk of The Circuit Court
fa Recording pursuant to the Uniform Commercial Code.
1. Debtor(s) Name(s) anJ Addnss(es) (last name first) 2. Secured Party(ies) and Addna(es) This sparx for CINk's uw ONLY
~ DG~IINI~1 LZIF. ~IiSSUIi?~NCE
Avbert Nelson COI~ANY
2721 S. U.S. #1, Suite 8 111 Westmotrt Road South
Ft. Pierce, FL 33450 - Waterloo, Ontario, Canada
3. This Statement covers the fdlowirg type (or items) of PERSONAL PROPERTY, FIXTURES„ or FARM PRODUCTS.
All personal property, equipment, inventory, fixtures, -
furnishings, utensils and appliances (except those
awned by tenants) of whatever nature, now or herever
affixed to or located on the real property and all
licenses, contract rights, leases, rents, issues and
profits of said real property, herein described on
Exhibit A hereto.
r - ~ - -
s
a. A desaiption of the real estate which "reasonably identifies what is dtstribed" and the name of the owner of
the real property.
Lots 5 and 6, Block 1, LINDAS~HILL, a subdivision
according to the Plat thereof as recorded in Plat Book 9, ~ ~g ~ ~ ~3
at page 56, Public Records of St. Lucie County, Florida
1
i 5. Maturity dare Gf any) 6. Number of sheets alt
7. Assignee(s) of Secured Party(ias) and Address(es) -
j
I -
8. ONE OR THE OTHER OF THESE TWO STATEMENTS MUST fiE CHE6KE0. (Otherwise it is not recordable.)
Check if true: The stamps required by ChaptN 201, F.S. have been placed on the promissory instrumatls
secured hereby, and will be ptautd on arty additional promissory instruments, advances or
similar instrument that may be so warred.
Check if true: ? Stamps are not required by Chapter 201, F.S.
~ 9, tf this statement is recorded without the Debtor's signature to perfect a secwity interest in collateral, check one of the following:
? Collateral was subject to a security intNest in anwher jurisdiction wMn it was brought into this state.
i
? Collateral is procecds of the original collateral described above in which a security interest was perfected.
10. Check if true: ~ Proceeds of Cdleteral ~e also atvtred. ? Products of Cdleteral are also covered.
I1. Filed with: Clerk of Circuit Court, St. Lucie County r FL
THE DOMINION LIFE ASSURANCE COMPANY
sy: ey:
R ER'1' N1~3~`~ or(s) Signature(s) of Scarred Party(iss)
i (tYPe name each signature) (Typ. name below sedt signature)
(1) Original (To be sent ro Clerk for rscordirg.) .