Net Worth Short Form Statement {PROB 48EZ}

OPROB 48EZ (Rev. 9/00) Social Security Last Name First Name Middle Name Number Instr uctions for Completing Net Worth Short For m Statem ent Having been convicted in the United States District Court, you are required to prepare and file with the probation officer an affidavit fully describing your financial resources, including a complete listing of all assets you own or control as of this date and any assets you have transferred or sold since your arrest. Amendments were made to 18 U.S.C. 3663(a)(1)(B)(i), 3664(d)(3), and 3664(f)(2), and Rule 32(b)(4)(F) to clarify that the assets owned, jointly owned, or controlled by a defendant, and liabilities are all relevant tothe courts decision regarding the ability to pay. Your Net Worth Statement should include assets or debts that are yours alone (I-Individual), assets or debts that are jointly (J-Joint) held by you and a spouse or significant other, assets or debts that are held by a spouse or significant other (S-Spouse or Significant Other)that you enjoy the benefits of or make occasional contributions toward, and assets or debts that are held by a dependent (D-Dependent) that you enjoy the benefits of or make occasional contributions toward. The court may require relating to such other factors as the court deems appropriate (see 18 U.S.C. 3664(d)(3)). If you are placed on probation or supervised release (or other types of supervision), you may be periodically required to provide updated information fully describing your financial resources and those of your dependents, as described above, to keep a probation officer informed concerning compliance with any condition of supervision, including the payment of any criminal monetary penalties imposed by the court (see 18 U.S.C. 3603). Please complete the Net Worth Short Form Statement in its entirety. You must answer None to any item that is not applicable to your financial condition. Attach additional pages if you need more space for any item.All entries must be accompanied by supporting documentation (see Request for Net Worth Statement Financial Records (Prob. 48A)). Sign and date Page 2 (including any attached pages). Also, sign, date, and attach the Declaration of Defendant or Offender Net Worth & Cash Flow Statements (Prob. 48D). <<<<<<<<<********>>>>>>>>>>>>> 2OPROB 48EZ Page 2(Rev. 9/00) NET WORTH S HORT FORM STATE MENT NOTE : I = Individual J = Joint S = Spouse/Significant Other D = Dependent ASSETS Include below all cash on hand, bank accounts, securities, money owed to you by others, life insurance, safe deposit boxes or storagefacilities, motor vehicles, real estate, mortgage loans owed to you, other assets, anticipated assets, and business holdings. I/J Type of Asset Location of Asset (e.g., bank, Fair Market or Actual Value S/D (e.g., cash, bank account) including account number) Include below all assets transferred or sold since your arrest with a cost or fair market value of more than $500.00, or assets thatsomeone else is holding on your behalf. I/J Type of Asset Date Sold or Transferred Fair Mar ket or Actual Value S/D Identify below any assets you will liquidate to satisfy any criminal monetary penalty that may be imposed, and/or describe the prospect of increase in assets. I/J Type of Asset Fair Market or Actual Value S/D LIABILITIES Include below all charge accounts and lines of credit, mortgage balances, other debts, civil suits, and bankruptcy filings. I/J Type of Debt (e.g., credit card) Debt Owed to (e.g., name, Balance Outstanding S/D account number) Signature Date