Fill and Sign the Financial Form

PERSONAL FINANCIAL DISCLOSURE STATEMENT * * * To:       Date:       Individual Information Name:       Address:       City:       State    Zip       Occupation:       Phone:       Current Assets Current Liabilities Cash on Hand or in Banks       Notes Payable (Secured)(Schedule F)       Other Cash:       Notes Payable (Unsecured)(Schedule G)       Real Estate (other than residence Schedule A)       Real Estate Mortgages Payable (Schedule H)       Residence       Auto Loans (Schedule I)       Motor Vehicles (Schedule B)       Unpaid Taxes and Interest       US Government Securities (Schedule C)       Due to Brokers       Non-Marketable Securities (Schedule D)       Open Accounts       Stocks (Schedule E)       Credit Cards (List):       Other Personal Property                   Life Insurance Cash Value                   Business Interests                   Notes Receivable                   Other Assets: Other:                                                                                     Total Liabilities                               TOTAL OF ALL ASSETS                   LESS TOTAL OF ALL LIABILITIES       Total Assets       NET WORTH       Individual Income Information (Annual) Salary       Bonus       Commissions       Dividends       Rental Income       Other Income (List):                         Total Income       Contingent Liabilities Guarantor, Co-maker       Lease or Contracts       Legal Claims       Other:             Financial Statement page - 1 - Initials: ________ __________ SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired       $       $                   $       $                   $       $                   $       $                   $       $                   $       $             Total $       $       SCHEDULE “B” MOTOR VEHICLES Description of Motor Vehicles Cost Value       $       $             $       $             $       $             $       $             $       $             $       $       Total $       $       SCHEDULE “C” U.S. GOVERNMENT SECURITIES Description of Stock or Bond Date Acquired Par Value Market Value             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “D” NON MARKETABLE SECURITIES Description Date Acquired Par Value Market Value             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “E” STOCKS Company Shares Date Acquired Par Value Market Value                   $       $                         $       $                         $       $                         $       $                         $       $                         $       $                         $       $                         $       $       Total $       $       Financial Statement page - 2 - SCHEDULE “F” NOTES PAYABLE SECURED Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “G” NOTES PAYABLE UNSECURED Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “H” REAL ESTATE MORTGAGES Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       SCHEDULE “I” AUTO LOANS Description Date Balance Payment (m/yr)             $       $                   $       $                   $       $                   $       $                   $       $                   $       $       Total $       $       I certify this Statement to be true and correct as of the date indicated: _________________________________ Signature Financial Statement page - 3 -