\PROB 48(Rev. 9/00)

Last Name First Name Middle NameSocial Security

Number

Instructions for Completing Net Worth Statement

Having been convicted in the United States District Court, you are required to prepare and file with theprobation offlcer 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. Amendmentswere made to 18 U.S.C. $$ 3663(aXlXBXi), 3664(dX3), and3664(f)(2), and Rule 32(b)(4XF) to clari$, thatthe assets owned, jointly owned, or controlled by a defendant, and liabilities are all relevant to the court'sdecision regarding the ability to pay. Your Net Worth Statement should include assets or debts that are yoursalone (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 thebenefits 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 periodicallyrequired to provide updated information fully describing your financial resources and those of yourdependents, as described above, to keep a probation officer informed concerning compliance with anycondition of supervision, including the payment of any criminal monetary penalties imposed by the court (see18 U.S.C. $ 3603) .

Please complete the Net Worth Statement in its entirety. You must answer "None" to any item that is notapplicable to your financial condition. Attach additional pages if you need more space for any item. Allentries must be accompanied by supporting documentation (see Request for Net Worth Statement FinancialRecords (Prob. 48A)). Initial and date each page (including any attached pages). Also, sign, date, and attachthe Declaration of Defendant or Offender Net Worth & Cash Flow Statements (Prob. 48D).

\PROB 48(Rev. 9/00)

Page 2 of

Last Name

NOTE: I= Ind i v i dua l J : Jo in t

NET WORTH STATEMENT

S: Spouse/Significant Other D: Dependent

ASSETS

BANK ACCOUNTS (lnclude all personal and businesses checking and savings accounts, credit unions, money markets, certificates of deposit,IRA and KEOGH accounts, Thrift Savings, 401K, etc.)

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Name of Inst i tut ion AddressType ofAccount

AccountNumber

Personal orCommercial

Balance

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SECURITIES (lnclude all stocks in public corporations, stocks in businesses you own or have an interest in, bonds, mutual funds,U.S. Government securities. etc.)

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Number o fUnits

Fair MarketValue

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MONEY OWED TO YOU BY OTHERS (lnclude all money owed to you by any person or entity.)

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Name and Address ofDebtor

Amount

Owed to YouReason Owed

to YouDate Money

LoanedRelationship

to Debtor(if any)

Monthly

Paymentor Date

FullPaymentExpected

Is DebtCollectible ?

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Initials _ Date

\PROB 48(Rev, 9i00)

Page 3 of

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LIFE INSURANCE (lnclude type of policy [whole life, variable, or term], face amount [the stated amount of coverage] and cashsuffender v4lue [the value of the investment portion of a whole life or variable policy.])

TIJS/D

Name and Address ofCompany and Name

of Beneficiary

PolicyNumber

Type ofPolicy

FaceAmount

CashSurrender

Value

AmountBorrowed

AmountYou CanBorrow

SAFE DEPOSIT BOXES OR STORAGE SPACE FACILITY (lnclude all safe deposit boxes or storage space you rent or places youhave access to in which others are holding assets or items belonging to you.)

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of Box or Faci l i tv LocationBox Number

or Snace Contents Fair Market Value

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MOTOR VEHICLES (lnclude all cars, trucks, mobile homes, motorcycles, all terrain vehicles, boats, airplanes, etc.)

IIJS/D

Year, Make & LicenseNumber/Vehic le

Identif ication Number

Mileage Loan/LeaseBalance(if any)

Date Loan/LeaseWi l lbe Pa id Of f

o r Ends

MonthlyPayment

Fair MarketValue

REAL ESTATE (lnclude propefty, parcels, lots, t imeshares, and developed land with bui ldings.)

TIJS/D

Real Estate Address(include county and state)/

Mortgage Companyor Lien Holder

PurchaseDate

PurchasePrice

MortgageBalance( i f any)

DateMortgage

Wil l be Paidoff

MonthlyPaymenl

Fair MarketValue

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MORTGAGE LOANS OWED TO YOU (lnclude name, address, and relationship [if any] to the mortgagee [the party that bought thereal estate you sold and is making payments to youl.)

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Mortgagee (name & address)/Relat ionship to Mortgagee

MortgageBalance

Date MortgageWil l be Paid

off

BalloonPayment?

If Yes. Date?

MonthlyPayment

Is DebtCollectible?

Initials Date

\PROB 48(Rev. 9/00)

Page 4 of

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OTHER ASSETS (lnclude any cash on hand, jewelry, art, paintings, coin collections, stamp collections, collectibles, antiques,copyrights, patents, etc.)

IIJS/D

Descript ion LoanBalance(if any)

Date LoanWil l be Paid

off

MonthlyPayment

Where is AssetLocated?

Fair MarketValue

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ANTICIPATED ASSETS (lnclude 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 ofany succession or estate.)

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Amount Received orExpected to Receive

DateExpected to

Receive

Reason You Expect This Name and Address of Person or CompanyThat Can Verify This (e.g., attorney, financial

inst i tut ion, executor)

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TRUST ASSETS (lnclude all trusts in which you are a grantor or donor [the person who establishes the trust], the trustee or fiduciary[who controls the trust assets and income or the beneflciary who has or will receive benefits from the trustl.)UJS/D

Name of Trust/Taxpayer ID#

Value ofTrust

Your Annual Income From Trust Your Interest in Trust Assets

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BUSINESS HOLDINGS (lnclude all businesses in which you have an ownership interest or with which you had an affiliation withinthe last three years; e.9., self-employed sole proprietor, officer, shareholder, board member, partner, associate, etc.) Complete Section N(attach additional pages, if necessary).

UJS/D

Name and Addressof Business/

Taxpayer I.D.#

Type ofBusinessEntity

Industry ofBusiness

DateBusinessStarted

CapitalInvestment

to Start

YourOwnership

InterestPercentage

Sale Price orFair Market

Value of YourInteresti.i...:4:!

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Initials _ Date

SPROB 48(Rev. 9/00)

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INCOME TAX RETURNS

Type of Income Tax Return Filed Last Fil ing Year Years of Last 5 Income Tax ReturnsYou Will Submit to the Probation

Officer

lndividual (Form 1040)

Partnership/Limited Liability Company(Form 1065)

Corporation (Form I 120)

S Corporation (Form I 120S)

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TRANSFER OF ASSETS (lnclude any assets you have transferred or sold since the date of your arrest with a cost or fair market valueof more than $500.00. Also list any assets that someone else is holding on your behalf.)

UJs/D

Description of Asset/Reason

Tra nsferred/Sold

Date ofTransfer/Sale

OriginalCost

Amount YouReceived, if

Any

Name o fPurchaser or

Person Holdingthe Asset

Sale Price orFair Market Value

at Transfer

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NAMES OF SHAREHOLDERS OR PARTNERS (lnclude al l shareholders, off icers, and/or partners, indicating each respectiveownership interest.)

Name of Business Names of Shareholders/PartnersOwnership Interest

Percentase$Siiitiii$i r

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Initials Date

SPROB 48(Rev. 9/00)

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ASSETS YOU WILL LIQUIDATE (lnclude all assets you intend to liquidate to satisf any criminal monetary penalties that may beimposed,)

Asset Description Estimated Valueof Asset

Date You WillLiouidate

Current Location of Assetif real property, county and state)

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PROSPECT OF INCREASE IN ASSETS (Give a general statement of the prospective increase of the value of any asset you own.)

Initials Date

\PROB 48(Rev. 9/00)

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LIABILITIES

CHARGE ACCOUNTS AND LINES OF CREDIT (lnclude all bank credit cards, lines of credit, revolving charge accounts, etc.)

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Type ofAccountor Card

Name and Addressof Creditor

CreditL imi t

AmountOwed

CreditAvai lable

MinimumMonthlyPayment

OTHER DEBTS (lnclude mortgage loans, notes payable, del inquent taxes, and chi ld support.)

TIJS/D

Owed To Address Relationship(i f anv)

AmountOwed

Reason

Owed

Monthly

Pavment

PARTY TO CML SUIT (lnclude any civil lawsuits vou have ever been a Dartv to.)

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UJS/D

Name of Plaint i f fin the Case

Court of Jurisdictionand County

CaseNumber

Date of SuitFiled

Date ofJudsment

Judgment Amount/Unpaid Balance

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BANKRUPTCY FILINGS (lnclude information requested for any Chapter 7, 1 l, or 13 bankruptcy filings you have ever been a partyto as an individual or as a business entity.TIJS/D

Type of Bankruptcy(Voluntary or Involuntary)/

Name and Address of Trustee

BankruptcyCase

Number

Bankruptcy Courtof Jurisdiction

County and State ofDischarge

Date Filed Date ofDischarge

Signature Date