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Request For Statement Of Account And List Of Collateral

[date]

From: [name and address of Debtor]

To: [name and address]

I, [name], the undersigned Debtor, executed a Security Agreement dated [date]. Pursuant to my rights as provided by Section 9-208 of the Uniform Commercial Code, I hereby state that I believe the aggregate amount of my unpaid indebtedness to be ........ dollars ($........) and that [collateral] is the Collateral I believe to be subject to the ecurity Agreement.

Debtor demands a written correction or approval of this Statement within two (2) weeks of its receipt by Secured Party.

Debtor agrees to pay any charges for such Statement by Secured Party as provided by Section 9-208 of the Uniform Commercial Code.

[signature]

Debtor