1. The name of the lender is _________. The lender does business under the assumed name of _________. The lender's principal place of business within this state is No. _________ _________ street, _________ county, _________[state]. [If the lender has no place of business within the state: The lender's principal place of business outside this state is No. _________ _________ street, _________ county, _________(state)]. [If the lender is a partnership: The lender is a partnership and the names of the partners are _________, _________ and _________]. [If the lender is a corporation or association:] The lender is a corporation [association] organized under the laws of the state of _________(or as the case may be)].

2. The name of the borrower is _________. The address of the borrower is No. _________ _________ street, _________ county, _________[state]. The interest of the borrower in the inventory, so far as known to the lender is _________[state interest].

3. The inventory subject to the lien, or which may become subject to it, is described in general terms as follows: _________[description of inventory]. The period of time during which loans and advances may be made under the terms of the agreement providing therefore and for such lien is from [Date], to [Date].