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Request for Statement of Account and List of Collateral
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 Security Agreement.
Debtor demands a written correction or approval of this Statement within two (--) 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.