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List of Creditors

(Required by Article 6 of the Uniform Commercial Code)

This is the List of Creditors as of [date] of [name] (Transferor) in a bulk transfer under Article 6 of the Uniform Commercial Code to be made on or after [date] to [name] (Transferee).

Nature or Basis of

Name of Creditor

Whether

Place

Claim; Whether or Claimant

Business

Claim

Where

Secured or

Address

Disputed

Contracted

Unsecured

Amount

The total amount of claims and debts scheduled is ---------- dollars ($----------).

[Signature]

Transferor

STATE OF ----------)

) s.s.:

COUNTY OF ---------)

I, [name], the person who subscribed to the foregoing list of creditors, do hereby swear that the list of creditors is complete and accurate according to the best of my knowledge, information, and belief.

[Signature]

Transferor

Acknowledgment

Sworn to before me the [dated]

Witness my hand and official seal.

[Signature]

[Name of Notary Public]

My commission expires: [date]

(Seal)