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UCC FINANCING STATEMENT
FOLLOW INSTRUCTIONS (front and back) CAREFULLY
A. NAME & PHONE OF CONTACT AT FILER [optional)
Rickie Turgeon 307-732-3044
B. SEND ACKNOWLEDGMENT TO: (Name and Address)
I Bank of Jackson Hole
Main Branch
P.O. Box 7000
Jackson, WY 83002
I
RECEIVED 12/15/2008 at 2:57 PM
RECEIVING # 944168
BOOK: 711 PAGE: 137
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
ûOú137
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THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY
1. DEBTOR'S EXACT FULL LEGAL NAME - insert only one debtor name (1a or 1b). do not abbreviate or combine names
1a, ORGANIZATION'S NAME
OR 1 b, INDIVIDUAL'S LAST NAME
Simkins
Ie. MAILING ADDRESS
P.O. Box 224
FIRST NAME
Jody
CITY
Afton
MIDDLE NAME
M.
SUFFIX
STATE POSTAL CODE
WY 83110
COUNTRY
USA
Id. SEE INSTRUCTIONS
1e, TYPE OF ORGANIZATION
Individual
1f. JURISDICTION OF ORGANIZATION
Ig. ORGANIZATIONAL ID #, if any
NONE
2. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME· insert only one debtor name (2a or 2b) - do not abbreviate or combine names
2a. ORGANIZATION'S NAME
OR 2b. INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX
Simkins Kris H.
2c, MAILING ADDRESS CITY STATE I POSTAL CODE COUNTRY
P.O, Box 224 Afton WY 83110 USA
2d, SEE INSTRUCTIONS I ADD'L INFO RE T2e. TYPE OF ORGANIZATION 21. JURISDICTION OF ORGANIZATION 2g, ORGANIZATIONAL ID #, If any
ORGANIZATION I d"d I 5a NONE
DEBTOR I n IVI ua 1 I
3. SECURED PARTY'S NAME (or NAME of TOTAL ASSIGNEE of ASSIGNOR SIP). Insert only one secured party name (3a or 3b)
3a. ORGANIZATION'S NAME
Bank of Jackson Hole
OR 3b, INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX
3c. MAILING ADDRESS CITY STATE rOSTAL CODE COUNTRY
P.O. Box 7000 Jackson WY 83002 USA
4. This FINANCING STATEMENT covers the following collateral:
All furniture. fixtures. inventory and equipment on that certain Real Property located at 970 South Washington Avenue. Afton, WY 83110,
more particularly described as Lot 29 of the Airport Addition Fifth Filing to the Town of Afton, Lincoln County, Wyoming as described on the
official plat filed on March 26, 2007 as Instrument No. 927852 of the records of the Lincoln County Clerk; whether any of the foregoing is
owned now or acquired later; all accessions. additions, replacements. and substitutions relating to any of the foregoing; all records of any
kind relating to any of the foregoing; all proceeds relating to any of the foregoing (including insurance, general intangibles and other accounts
proceeds).
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i ·1 ~ I
,j
Debtor 2
FILING OFFICE COPY - UCC FINANCING STATEMENT (FORM UCC1) (REV, D5/22/02)
Harland Financial Solutions
400 S.W. 6th Avenue, Portland, Oregon 97204
UCC FINANCING STATEMENT ADDENDUM
FOLLOW INSTRUCTIONS front and back CAREFULLY
9. NAME OF FIRST DEBTOR (1a or 1b) ON RELATED FINANCING STATEMENT
ga. ORGANIZATION'S NAME
OR
9b, INDIVIDUAL'S LAST NAME
Simkins
FIRST NAME
Jody
MIDDLE NAME, SUFFI
M.
OOû1.38
10, MISCELLANEOUS:
THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY
11. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME - insert only one name (11a or 11b) - do not abbreviate or combine names
-
11a. ORGANIZATION'S NAME
OR 11 b, INDIVIDUAL'S LAST NAME FIRST NAME MIDDLE NAME SUFFIX
11c, MAILING ADDRESS CITY STATE rOSTAL CODE COUNTRY
11 d. SEE INSTRUCTIONS I :DD'L INFO RE 111 e. TYPE OF ORGANIZATION 111. JURISDICTION OF ORGANIZATION 11g, ORGANIZATIONAL ID #, if any
ORGANIZATION n NONE
DEBTOR I I I
12. 1 ADDITIONAL SECURED PARTY'S or rl ASSIGNOR SIP'S NAME - insert only one name (12a or 12b)
12a. ORGANIZATION'S NAME
OR 12b. INDIVIDUAL'S LAST NAME SUFFIX
FIRST NAME MIDDLE NAME
12c. MAILING ADDRESS CITY STATE I POSTAL CODE COUNTRY
13. This FINANCING STATEMENT covers 0 timber to be cut or 0 as-extracted 16. Additional collateral description:
collateral, or is filed as a 0 fixture filing.
14, Description of real estate:
Lot 29 of the Airport Addition Fifth Filing to the Town of
Afton. Lincoln County, Wyoming as described on the official
plat filed on March 26. 2007 as Instrument No. 927852 of
the records of the Lincoln County Clerk
15. Name and address of a RECORD OWNER of above-described real estate
(if Debtor does not have a record interest):
17. Check 2!!!Y if applicable and check 2!!!Y one box. or n Decedenfs Estate
Debtor is a n Trust or n Trustee acting with respect to property held in trust
18. Check 2!!!Y If applicable and check 2!!!Y one box.
t- Debtor is a TRANSMITTING UTILITY
¡. Filed in connection with a Manufactured-Home Transaction - effective 30 years
Filed in connection with a Public-Finance Transaction - effective for 30 years
FILING OFFICE COpy - UCC FINANCING STATEMENT ADDENDUM (FORM UCC1Ad) (REV. OS/22/02)
Harland Financial Solutions
400 S.W. 6th Avenue, Portland, Oregon 97204