Net Worth Statement {PROB 48}

OPROB 48 (Rev. 9/00) Social Security Last Name First Name Middle Name Number Instr uctions for Completing Net Worth Statement 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 assetsyou 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 to the 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, assetsor 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. 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 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 entriesmust be accompanied by supporting documentation (see Request for Net Worth Statement Financial Records (Prob. 48A)). Initial and date each page (including any attached pages). Also, sign, date, and attach the Declaration of Defendant or Offender Net Worth & Cash Flow Statements (Prob. 48D). <<<<<<<<<********>>>>>>>>>>>>> 2OPROB 48 Page 2 of (Rev. 9/00) Last Name - NET WORTH S TATEMENT NOTE : I = Individual J = Joint S = Spouse/Significant Other D = Dependent ASSETS BANK ACCOUNTS (Include all personal and businesses checking and savings accounts, credit unions, money markets, certificates of deposit, IRA and KEOGH accounts, Thrift Savings, 401K, etc.) I/J Type of Account Personal or Name of Institution Address Balance S/D Account Number Commercial A n io t c e S SECURITIES (Include all stocks in public corporations, stocks in businesses you own or have an interest in, bonds, mutual funds, U.S. Government securities, etc.) I/J Number of Fair Market Name and Kind of Security Location of Security S/D Units Value B n o i t c e S MONEY OWED TO YOU BY OTHERS (Include all money owed to you by any person or entity.) I/J Name and Address of Amount Reason Owed Date Money Relationship Monthly Is Debt S/D Debtor Owed to You to You Loaned to Debtor Payment Collectible ? (if any) or Date Full Payment Expected C n o i t c e S Initials Date <<<<<<<<<********>>>>>>>>>>>>> 3OPROB 48 Page 3 of (Rev. 9/00) Last Name - LIFE INSURANCE (Include type of policy [whole life, variable, or term], face amount [the stated amount of coverage] and cash surrender value [the value of the investment portion of a whole life or variable policy.]) I/J Name and Address of Policy Type of Face Cash Amount Amount S/D Company and Name Number Policy Amount Surrender Borrowed You Can D of Beneficiary Value Borrow n o i t c e S SAFE DEPOSIT BOXES OR STORAGE SPACE F ACILITY (Include all safe deposit boxes or storage space you rent or places you have access to in which others are holding assets or items belonging to you.) I/J Name and Address Box Number Contents Fair Market Value E S/D of Box or Facility Location or Space n o i t c e S MOTOR VEHICLES (Include all cars, trucks, mobile homes, motorcycles, all terrain vehicles, boats, airplanes, etc.) I/J Year, Make & License Mileage Loan/Lease Date Loan/Lease Monthly Fair Market S/D Number/Vehicle Balance Will be Paid Off Payment Value F Identification Number (if any) or Ends n o ti c e S REAL ESTATE (Include property, parcels, lots, timeshares, and developed land with buildings.) I/J Real Estate Address Purchase Purchase Mortgage Date Monthly Fair Market S/D (include county and state)/ Date Price Balance Mortgage Payment Value Mortgage Company (if any) Will be Paid G or Lien Holder Off n o i t c e S MORT GAGE LOANS OWED TO YOU (Include name, address, and relationship [if any] to the mortgagee [the party that bought the real estate you sold and is making payments to you].) I/J Mortgagee (name & address)/ Mortgage Date Mortgage Balloon Monthly Is Debt S/D Relationship to Mortgagee Balance Will be Paid Payment? Payment Collectible? H Off If Yes, Date? n o ti c e S Initials Date <<<<<<<<<********>>>>>>>>>>>>> 4OPROB 48 Page 4 of (Rev. 9/00) Last Name - OTHER ASSETS (Include any cash on hand, jewelry, art, paintings, coin collections, stamp collections, collectibles, antiques, copyrights, patents, etc.) I/J Description Loan Date Loan Monthly Where is Asset Fair Market S/D Balance Will be Paid Payment Located? Value (if any) Off I n o ti c e S ANTICIPATED ASSETS (Include any assets you expect to receive or control from lawsuits for compensation or damages, profit sharing, pension plans, inheritance, wills, or as an executor or administrator of any succession or estate.) I/J Amount Received or Date Reason You Expect This Name and Address of Person or Company S/D Expected to Receive Expected to That Can Verify This (e.g., attorney, financial Receive institution, executor) J n o i t c e TRUST ASSETS (Include all trusts in which you are a grantor or donor [the person who establishes the trust], the trustee or fiduciary S [who controls the trust assets and income or the beneficiary who has or will receive benefits from the trust].) I/J Name of Trust/ Value of Your Annual Income From Trust Your Interest in Trust Assets S/D Taxpayer ID# Trust BUSINESS HOLDINGS (Include all businesses in which you have an ownership interest or with which you had an affiliation within the last three years; e.g., self-employed sole proprietor, officer, shareholder, board member, partner, associate, etc.) Complete Section N (attach additional pages, if necessary). I/J Name and Address Type of Indus