DEBTOR'S NAME:___________________________________________________

ADDRESS: __________________________________________________

___________________________________________________________

SS # (for each debtor): _________________________________________

Secured Party's Name: ____________________________________________

Address: _____________________________________________________

               ___________________________________________________

Date Born:  ____________________________

Fill in as much as possible in this section as only living creatures have a geneology.
Parents Names
& birth dates: _____________________________________________ 
                                 Name                                                                                   Birth Date
                 _____________________________________________
                    Name                                                                                   Birth Date         
Grandparents:  ____________________________________________      
                    Name                                                                                   Birth Date
                  _____________________________________________
                    Name                                                                                   Birth Date         
                  _____________________________________________                                Name                                                                                   Birth Date
                  _____________________________________________
                    Name                                                                                   Birth Date
Great
Grandparents: _______________________________________________                            Name                                                                                   Birth Date 
                  _______________________________________________
                    Name                                                                                   Birth Date
                     _______________________________________________                                Name                                                                                   Birth Date                  
                  _______________________________________________
                    Name                                                                                   Birth Date

Please attach copies of birth certificates (we don't need originals for this) for each strawman claimed. They must be certificates from the state, not from the local muncipality.

Doing the Treasury Package? Go to "http://www.state.[birth state's 2-letter name].us" to order a birth certificate.You will receive your UCC-1 form(s) with complete instructions for filing  We are always here for consultation as well!

For your Lien and/ or Security Agreement (if applicable): On a separate piece of paper, type or write legibly all collateral you are claiming, such as:

1. Driver License and/or other licenses: type of license, number and State of issuance;
2. names and SS# of all minors whose 'strawmen' you are claiming (specify whether your children or your ward);
3. cars & other vehicles: type (e.g. car; tractor w/each part; etc.), ID numbers, year, make & model;
4. real estate: list municipality, county, state, deed book & page number, street address;
5. any other specific personal property, but you must give it an ID number if it hasn't one already.

The Security Agreement has wording that "All property of DEBTOR is hereby the property and security of the Secured Party..." and other inclusive language so it isn't necessary to give an ID number to each item in the DEBTOR's possession.

Have a special identifying number for your Agreement? __________
If not, we will assign it one.

---

Please check which services you are ordering:

Security Agreement (attach info/asset sheet) - $150 ___
Lien (attach info/asset sheet) - $125 ___
UCC 1 Financing Statement -  $100 ___
attach copy(ies) of birth certificate(s)

Treasury Package   -   $200 ___

Specific POA  -  $135  ____
Hold Harmless and Indemnity Agreement  -  $150 __
Copyright Notice  -  $135 _____

Package Deals:
Security Agreement, Lien & UCC-1 filing -  $350 ___

All seven (7) documents:  $900 _____
                                    
Pay Electronically by copying and pasting this form into an e-mail, completing & sending it and then clicking the Donate button:

OR

Mail completed form and attachments with payment in Postal Money Order, preferably with the 'pay to' line left blank or made payable to:
Send my finished documents to:

Name: _____________________________________________________

Address: ___________________________________________________

              ___________________________________________________

Phone: _____________________ E-mail: __________________________