Debtor Request for Certified Statement from Secured Party

TO: ________________________
____________________________
____________________________
____________________________

Attention: __________________

FROM: ______________________
____________________________
____________________________
____________________________

Attention: __________________ 

Dated: ___________________________ 

Pursuant to Section 9-208 of the Uniform Security Code, ____________________, as debtor, requests that the Secured Party, __________________________, provide: 

A statement of account, indicating the aggregate amount of unpaid indebtedness as of _______________________. Approval of the following statement of collateral as constituting a correct statement of the collateral claimed by Secured Party as of ______________________.

See Exhibit "1" to this form.

The statement above is (check one): 

__ Accepted as correct 

__ Incorrect, our corrections or response are attached hereto 

Dated: ____________________________________ 

________________________, by: 

___________________________________________________ 
An Authorized Officer 

Title: ___________________________________________	           

_________________________, by: 

__________________________________________________ 
An Authorized Officer							           

Title: _____________________________________ 

Debtor Request for Certified Statement from Secured Party
Review List

This review list is provided to inform you about this document in question and assist you in its preparation.  This is request from a debtor to secured party to certify the exact amount then due from debtor.  This is useful for a variety of reasons, among them for the benefits of your financial statements and your auditors, should you have them.

1.	Make multiple copies.  Put one in your financial file, another in the secured party’s file, and the other in a follow-up file.