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New MexicoKey & Affi liatedPersonApplication

New Mexico Gaming Control Board

4900 Alameda Blvd NE Albuquerque, NM 87113

Phone: (505) 841-9700

Fax: (505) 841-9725Web: www.nmgcb.org

(REVISED DECEMBER 2010)

STATE OF NEW MEXICOGAMING CONTROL BOARD

4900 Alameda Blvd. NE

Albuquerque, NM 87113

Phone (505) 841-9700

FAX (505) 841-9725

A MESSAGE FROM THE DIRECTOR:

Dear Applicant:

Thank you for your interest in becoming certifi ed as a key person or affi liated person involved in the

gaming industry operating in New Mexico.

The certifi cation process you will be undergoing is a rigorous one designed to ensure that the citizens

of New Mexico can enjoy gaming in a fair and honest environment. The information requested in

this application is very extensive, but only by qualifying and regulating carefully those who become

involved in gaming in New Mexico can we ensure our citizens that the industry and everyone involved

in it will give them a fair shake. We take our regulation of the industry very seriously, particularly the

issuance of gaming licenses.

During the licensing process, we will conduct a thorough investigation of your background. We also

require you to sign and to have notarized a statement attesting to the fact that all of the information

supplied in the application is true and correct to the best of your knowledge and belief. This attesta-

tion is signed under the penalty of perjury and can result in serious consequences if signed falsely.

You must pass all of our qualifi cations in order to be issued a gaming certifi cation that will give you

the privilege of conducting gaming in our state.

I wish you all the best in your endeavors in New Mexico. The Gaming Control Board staff and I look

forward to working with you.

i


Applying for Your

Key & Affi liated Person Certifi cation(For Manufacturers, Distributors, & Racetracks)

Key & Affi liated Person Application Instructions

OBTAIN YOUR APPLICATION Applications can be obtained from:


4900 Alameda Blvd NE


Or downloaded from website at:

www.nmgcb.org

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SUBMIT YOUR APPLICATION Deliver to:


Attention: Licensing & Background Division

4900 Alameda Blvd NE


Make check or money order payable to New Mexico Gaming Control Board

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FILL OUT YOUR APPLICATION Items you must provide:

• Application forms (completed & notarized signatures)

• Supporting documentation as specifi ed on the attached Application

Checklist or elsewhere in the application

• The Board reserves the right to request additional information if necessary

to complete your background investigation.

You Must Be 21 Years of Age to Apply for a Gaming Certifi cation Application Checklist

INCOMPLETE APPLICATIONS SHALL NOT BE ACCEPTED

APPLICATION COMPLETED & SIGNED IN BLACK/BLUE INK

If you are unsure if a question applies to you or what information the form is asking you to provide, contact the

Gaming Control Board Licensing and Background Division for clarifi cation. If the available space is insuffi cient,

precede each answer using the corresponding Attachment number with a “page ___ of ___”page. Sign and date

each page.

ALL FORMS SIGNED & ATTACHED

The following items and forms must be signed and returned with the application:

o TWO (2), current passport style photos and must be satisfactory to the Board.

o Photocopy or scanned copy of driver's license.

o Affi rmation & Consent - Notarized

o Applicant's Investigation Authorization and Request to Release Information - Notarized

o Copies of your federal and state income tax returns, W2's, 1099's, 1098's and K-1's for the past three (3)

years with your signatures. If your spouse fi les separate tax return(s), they must accompany your

application.

o All international tax returns should be translated into English.

COPY OF BIRTH CERTIFICATE AND VALID PASSPORT (IF APPLICABLE)

Supply proof of identity and date of birth by a copy or certifi ed copy providing the following documents:

o Copy of birth certifi cate from the Vital Statistics offi ce in the state you were born;

o Valid U.S. passport (all pages);

o If not a U.S. citizen, valid passport and Visa issued by country of citizenship (all pages);

o Certifi cate of Naturalization with photo or Alien Registration Card/Resident Card.

APPLICANT FBI FINGERPRINT CARD

o Provide two fi ngerprint cards and ensure each card is properly completed and signed.

NOTE: Fingerprints are to be taken by a law enforcement agency, or upon Board approval, another entity

providing the service of a certifi ed identifi cation technician.

o International applicants will submit national, district, and/or local police certifi cations from the presiding

law enforcement agency in a sealed envelope; or, in appropriate cases translated by a third party.

o International applicants will submit court histories and appropriate certifi cations from the presiding court

agency in a sealed envelope; or, in appropriate cases translated by a third party.

o International applicants will submit a credit report by a mutually agreed upon and/or internationally

recognized reporting company.

$100 APPLICATION FEE

o Submit $100 non-refundable application fee for a Certifi cation of Finding of Suitability.* Make the check

or money order payable to NEW MEXICO GAMING CONTROL BOARD.

*New Mexico law requires applicants to fund the cost of their background investigations. Investigative fees are based on a rate of $50

per hour for investigations and charges for all out-of-pocket expenses incurred during the investigation, such as travel costs and costs to

reproduce documents. This investigative cost will be billed to the licensed entity.

DELIVER APPLICATION

o Deliver application to:


Attention: Licensing & Background Division

4900 Alameda Blvd. NE


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GAMING CONTROL BOARD Key & Affi liated Person Application Instructions

iii

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5

6

3

NMGCB

Use Only

Initial or

N/A

Signature of Applicant: Date:

NMGCB

Use Only

Initial or

N/A

GAMING CONTROL BOARD

IF APPLICABLE: If you have attached any of the additional Attachment forms, indicate by placing your initials in the

box at the left hand column and indicate the number of pages in the space provided. If you have not used a particular At-

tachment form, so indicate by writing “N/A” in the box at the left hand column.

Key & Affi liated Person Application Instructions

INCOMPLETE APPLICATIONS SHALL NOT BE ACCEPTED

Signature of Applicant: Date:

Attachment A

Attachment D

Attachment C

Attachment B

Attachment E

Attachment H

Attachment G

Attachment F

Attachment I

Gaming License History

Residence Data

Attachment J

Family Information

Professional Licenses

Employment/Business

History

Child Support Obligation

Lawsuits, Judgments,

Liens, Bankruptcy

Number of Pages___

Financial Statements

Criminal History

Additional Information

Number of Pages___

Number of Pages___

Number of Pages___

Number of Pages___

Number of Pages___

Number of Pages___

Number of Pages___

Number of Pages___

Number of Pages___

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NEW MEXICO GAMING CONTROL BOARD

KEY & AFFILIATED PERSON

APPLICATION FORM(REVISED DECEMBER 2010)

4900 Alameda Blvd. NE Albuquerque, NM 87113

Page 1 of 38

U.S. Citizen *If “No”, attach details and indicate Alien Registration

YES NO Registration Number:

*If YES, you must surrender and enclose your current work permit.

2. Do you currently possess a New Mexico Gaming Work Permit with the Entity you are currently applying for as a Key and Affi liated Person?

*If YES, indicate license type and number (if you need additional space use Attachment B).

Entity License #

DateSignature of Applicant

3. Do you or any member of your immediate family currently possess a New Mexico gaming license or are you an affi liated person with any other type of New Mexico gaming license?

KEY & AFFILIATED FEE.......$100.00 Check # Money Order #

FOR AGENCY USE ONLY Application Control # Entity Control #Universal Control #

*If “YES”, attach details

E-mail Address

Zip Code

Street Address Contact Phone Number

Mailing Address, if different from Street Address

City Length at This Address

Applicant’s Printed Name (last, fi rst, middle)

State

Name of licensed business where you will be working

Place of Birth (city, state, country)

( )

Country

Weight Hair ColorHeight

Date of Birth

Eye Color

Maiden/Married Names Used (Full Name) (Attach separate sheet if necessary) Nicknames, Aliases, Etc. Used (Full Name) (Attach separate sheet if necessary)

SexF M

Social Security Number Other Social Security Numbers Used

YES* NO

Drivers License Number & State Issued

ZipCity State

Are you replacing another key person?

Work Phone Number

Work Phone Number

( )

( )

Name of present employer, if different from above

Job Title

Occupation or Job Title

YES* NO *If “YES”, indicate name and title here

(Name) (Title)

Beginning with your current residence(s) and working backward, provide the following information with respect to each place where you have lived (including residences

while attending college or while in military service) during the last 15 years or since the age of 18, whichever is less (if you need additional space use Attachment A).

*If YES, give State, License Number & Details here (if you need additional space use Attachment B).

4. Have you or your spouse ever applied for a gaming license in this or any other jurisdiction, domestic tribal, or foreign, whether or not the license was ever issued?

*If YES, give State, License Number & Details here (if you need additional space use Attachment B).

5. Have you or any member of your immediate family ever been denied a gaming license, withdrawn a gaming license application or had any disciplinary action taken against any

gaming license that you have held, either individually or as part of an ownership group, in this or any other jurisdiction?

6. Are you under 21 years of age at the time of this application?

DATES

FROM:(MO/YR)

TO:(MO/YR)

ADDRESSNAME, ADDRESS & PHONE NUMBER OF LANDLORD OR

MORTGAGE HOLDER, IF KNOWN

OWN OR

RENT

*If YES, attach a copy of all pages.1. Do you own a current passport?

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES NO

MARITAL INFORMATION

Page 2 of 38

FAMILY INFORMATION

New Mexico Gaming Control Board 4900 Alameda Blvd. NE, Albuquerque, NM 87113


If you need additional space use Attachment C

Spouse’s Full Name (Maiden Name if Female) Social Security Number Date of Birth Place of Birth

Residence Address Wedding Date Location (City, County, State)

Spouse’s Employer Occupation Address of Employer

PREVIOUS MARRIAGES (If ever legally separated, divorced or annulled use Attachment C. If Female, include Maiden Name.)

Spouse’s Name City, County, StateWedding Date Nature of Order or Decree Date

Current Address (include zip code) Phone Number

Current Marital Status

Single Married Common-Law Separated Divorced Widowed

Name Date of Birth

CHILDREN (Include all natural, step-, and adopted children, and Maiden Name if Female)

PARENTS (If retired or deceased, list last address and occupation and Maiden Name if Female.)

Father

Spouse’s Name City, County, StateWedding Date Nature of Order or Decree Date

Current Address (include zip code) Phone Number

( )

( )

Mother

Father-In-Law

Mother-In-Law

Stepfather

Stepmother

Occupation

Are you currently subject to any child support order?

Name Date of Birth Place of Birth

Place of Birth

Current Address (include zip code) Zip CodeCity State

Name Date of Birth Place of Birth



*If YES, complete Attachment DYes* No


Date of Birth

Occupation


Date of Birth

Occupation


Date of Birth

Occupation


Date of Birth

Occupation


Date of Birth

Occupation


Date of Birth

EMPLOYMENT HISTORY

Page 3 of 38



Name

Relation to Applicant

Name and/or BusinessManager’s Name

Description of Duties

Title/Position Held

Reason for Leaving

Mailing Address

Dates (from-to)

• Please list all employment (including business ownership) by the applicant.

• List all employment by the applicant’s spouse in the last ten (10) years, as well as any gaming or gaming related industry employment prior to the last ten (10)

years.

• List any and all employment in any gaming or gaming related industry by any member of the applicant’s immediate family (“immediate family” means: spouse,

parents (including step and adoptive parents), spouses of parents, parents of spouse, siblings and their spouses, children and their spouses and anyone with

whom the applicant shares a residence or domicile regardless of their relationship to the applicant).

If you need additional space use Attachment E

Telephone Number

Zip CodeCity State

Name




Title/Position Held

Reason for Leaving

Mailing Address

Dates (from-to) Telephone Number

Zip CodeCity State

Name




Title/Position Held

Reason for Leaving

Mailing Address


Zip CodeCity State

YES* NODo you own any privileged or professional licenses individually or as part of an ownership group in New Mexico or any other domestic

or foreign jurisdiction (i.e., Liquor, Insurance, Real Estate, Racing, Accountant, Pilot, Attorney, Securities Dealer, Contractor, etc.).

If you need additional space, use Attachment F, Professional Licenses.

*If YES, please provide information below. If you need additional space, use Attachment F, Professional Licenses.

Type of License

Current Status

Issued By

Disciplinary Actions

Date Issued

Are you a gaming technician?

*If YES, please provide information below and attach copies of training certifi cation.

Type of License

Current Status

Issued By

Disciplinary Actions

Date Issued

Have you ever held a fi nancial interest in a gambling venture including but not limited to, a race course or dog track, lottery, casino, book-

making operation, card room, bingo parlor or pull tabs?

YES* NO

YES* NO

1.

2.

3.

*If YES, prvide information on Attachment F, Professional Licenses.

PROFESSIONAL LICENSES

of 38

MILITARY INFORMATION



CHARACTER REFERENCES

Name

Employer

Years Known Address (include zip code)

Business Address (include zip code)

Have you ever been tried by a military court martial or have you had charges fi led against you?

Grade/RankType of DischargeDates of ServiceService NumberBranch

(Please provide certifi ed copy of DD214 or equivalent foreign discharge document.)

Have you ever served in any armed forces?

Residence Phone

Business PhoneOccupation

SentenceDisposition

(convicted, acquitted, dismissed,

pleadings, etc.)

Name of Militant Organization

Filing ChargesDate and Location of

Charge or Arrest

Nature of Charge

or Arrest

EDUCATION

YES* NOActive Reserve

*If YES,

*If YES, complete the following chart.

High School Name

Other College/School Name

Other College/School Name

College/Vo-Tech Name Location Degree EarnedMajor Dates Attended Graduate

Location

Degree Earned

Major

Dates Attended Graduate

Location Degree EarnedMajor Dates Attended Graduate

Location

Degree Earned

Major

Dates Attended Graduate

Yes No

Yes No

Yes No

Yes No

Name

Employer



Residence Phone


Name

Employer



Residence Phone


Name

Employer



Residence Phone


Name

Employer



Residence Phone


Name

Employer



Residence Phone


YES* NO

of 38



*IF YOU ANSWERED “YES,” EXPLAIN IN DETAIL ON ATTACHMENT H AND ATTACH IT TO YOUR APPLICATION. FOR EACH

OFFENSE FOR WHICH YOU WERE ARRESTED OR CHARGED, YOU MUST OBTAIN AN OFFICIAL COPY OF DOCUMENTATION

FROM THE COURT WHERE YOU APPEARED, SHOWING THE FINAL DISPOSITION (OUTCOME) OF YOUR CASE. THIS

INFORMATION SHOULD INCLUDE WHETHER YOU WERE FOUND GUILTY OR NOT GUILTY AND THE PENALTY (MONETARY

FINE, TIME IN JAIL OR PRISON, OR PROBATION OR DEFERRED SENTENCE). IF YOU RECEIVED A DEFERRED JUDGMENT, A

DEFERRED SENTENCE, OR PROBATION, YOUR DOCUMENTATION MUST INCLUDE THE DATE THAT YOU WERE DISCHARGED

OR RELEASED FROM PROBATION OR OTHER SUPERVISION.

NOTICE: THE NEW MEXICO KEY AND AFFILIATED PERSON APPLICATION IS AN OFFICIAL DOCUMENT. IF YOU PROVIDE FALSE INFORMATION

ON YOUR APPLICATION OR DO NOT DISCLOSE ALL APPLICATION INFORMATION, YOUR LICENSE IS SUBJECT TO DENIAL OR REVOCATION AND

YOU MAY BE SUBJECT TO CRIMINAL PROSECUTION PURSUANT TO [60-2E-54 NMSA 1978]. THE GAMING CONTROL BOARD WILL CONDUCT A COM-

PLETE BACKGROUND INVESTIGATION AND WILL CHECK ALL SOURCES OF INFORMATION. THE FINGERPRINTS WHICH YOU ARE REQUIRED

TO SUBMIT WITH THIS APPLICATION WILL BE USED TO CHECK THE CRIMINAL HISTORY RECORDS OF THE FBI (FEDERAL BUREAU OF

INVESTIGATION) AND THE STATE OF NEW MEXICO.

CRIMINAL HISTORY

Have you ever been arrested or convicted of a felony, misdemeanor violation or violation of probation or any other court order, or any gambling

-related offense in this or any other country?

1.

2. Has your spouse ever been arrested or convicted of a felony, misdemeanor violation or violation of probation or any other court order, or any

gambling-related offense in this or any other country?

3. Has a criminal indictment information, or complaint ever been fi led or returned against you or your spouse, in this or any other country, but for

which you were not arrested or in which you were named as an un-indicted co-party or un-indicted co-conspirator in any criminal proceeding in

any jurisdiction?

4. To your knowledge, have you or your spouse been the subject of an investigation conducted by any government organization of an agency,

court commission, committee, grand jury or investigatory body (local, state, court provincial, federal, international, etc.)

5. Have you or your spouse ever been called to testify before or otherwise been questioned, interviewed, deposed or required to take a polygraph

exam by any governmental agency/organization, court, commission, committee, grand jury or investigative body (local, state, county, provincial,

federal, national, etc.) in any jurisdiction other than in response to a traffi c summons?

6. Have you or your spouse ever been subpoenaed to appear or testify before a federal, national, state, county grand jury, other criminal investigatory

agency or body, or any board or commission, or any civil, criminal or administrative proceeding or hearing?

7. Have you or your spouse ever had a criminal record expunged?

8. Are you or your immediate family currently being prosecuted or facing pending charges in any jurisdiction, for any offense, or are you on a

deferred prosecution or a deferred judgment and sentence for any offense?

9. Have you or your immediate family ever been identifi ed as habitual offender?

10. Have you or your immediate family ever been identifi ed as a member of an organized crime cartel?

Have you or your immediate family ever refused to cooperate with any offi cial investigative body involved in the investigation of crimes related

to gaming, offi cial corruption, or organized crime?

11.

• You must include ALL arrests, charges, and convictions since the age of 18 and prior to 18 if charged as a youthful offender regardless of the out-

come, even if the charges were dismissed or you were found not guilty.

• You must include ALL arrests, charges, and convictions regardless of the class of crime (felony, misdemeanor, and/or petty offense).

• You must include ALL serious traffi c offenses, including DWI; reckless driving; leaving the scene of an accident (hit and run); driving under denial,

suspension or revocation; or any other offense which resulted in your being taken into custody. Non-serious traffi c offenses should not be listed.

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

NOTICE: Do not rely upon your understanding that an arrest or charge is "not supposed to be on your record". A criminal

record was not cleared, erased, sealed or expunged unless you were given, and have in your possession, a written order from a

judge directing that action.


LEGAL HISTORY

Have you or your spouse as an individual, member of a partnership, or owner, director, or offi cer of a corporation, ever been a party to a

lawsuit, as either a plaintiff or defendant or in arbitration as either a claimant or defendant?

1.

2. Do you anticipate any legal action to be fi led against you or your spouse individually or on behalf of a business entity of which you are a principal,

through other individuals, through a trust or the like?

3. Has a complaint judgment, consent decree, settlement or other disposition related to a violation of federal, state or similar foreign antitrust,

trade or security law or regulation ever been fi led or entered against you or your spouse or a business entity of which you were a principal or

against a corporation for which you were an owner, offi cer or director?

4. Are you now or have you been delinquent in the repayment of any government-insured student loans?

5. Are you now or have you been delinquent in the payment or any judgments due to any government agency?

6.

7.

Have you, as an individual or principal of any form of business entity, ever fi led a bankruptcy petition or had such a petition fi led against you

or the business entity; or had a receiver, fi scal agent, trustee, reorganization trustee or similar person appointed for you or the business entity?

Have you ever as an owner offi cer or director of a corporation ever fi led a bankruptcy petition, had such a petition fi led against you or the

corporation; or had a receiver, fi scal agent, trustee, reorganization trustee or similar person appointed for you or the corporation?

* If you answered “YES” to any of the questions above or checked any boxes above, give details on Attachment G, Lawsuits, Judg-

ments, and Liens. Include any items currently under dispute or appeal. Attach and include all documents to provide your settlement

on any of these issues.

FINANCIAL HISTORY

Are you now or have you been delinquent in the fi ling of any tax returns with any taxing agency? 1.

2. Are you now or have you been delinquent in the payment of any taxes, interest, or penalties due to any taxing Agency?

3. Do you currently have a safety deposit box?

4. Do you now own, or have you ever owned, or otherwise derived a benefi t from assets held outside the United States, whether held in your own

name or another name, on your behalf or for another person or entity, or through other individuals or business entities, or in trust, or in any

other fashion or status?

5. Are you currently a party, or ever been a party, in any capacity, to any trust instrument?

6. Are your wages, earnings or other income subject to garnishment, attachment, charging order, voluntary wage execution or the like?

7. Complete Attachment I, Financial Statement, Net Worth Statement, Assets and Liabilities.

*If YES, please complete Attachment J, Additional Information, with supporting documents.

*If YES, please include all current information on Attachment I, Financial Statements, with supporting documents. For previous

information, please include information on Attachment J, Additional Information, with supporting documentation.

*If YES, fi ll in the name of the fi duciary institution:

*If YES, for current information, please complete Schedule I, Financial Statement. For previous information, please complete Attachment

J, Additional Information.

*If YES, for current information, please complete Attachment I, Financial Statement. For previous information, please complete At-

tachment J, Additional Information.

*If YES, please explain on Attachment G, Lawsuits, Judgments, Liens; and/or, Attachment D, Child Support Obligation; and/or,

Attachment I, Financial Statements.


Page 6 of 38

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO

YES* NO


PLEASE SUBMIT ALL EXECUTED AGREEMENTS OR DOCUMENTS THAT GRANT YOU ANY RIGHT TO ANY PERCENT OF OWNERSHIP OR

PERCENT OF INCOME FROM ANY GAMING BUSINESS WITH WHICH YOU ARE ASSOCIATED.

For INVESTORS, please submit audited statements of net worth and balance sheet fi nancial statements for the last three years. This would include personal and all busi-

ness interests of ownership of 5 percent of more. All fi nancials will need to be signed and the preparer must be identifi ed. All bank statements and other supporting

documents for all fi nancial assets and liability must be submitted for the latest year of the statement of net worth. International fi nancial schedules must be converted to

GAAP (generally accepted accounting principles).

Amount you have invested (or will be investing) in the gaming business for which you are submitting this application $1.

2.

3.

4. Has your interest in this gaming establishment been assigned, pledged or hypothecated to any person, fi rm, or corporation, or has any agreement been entered into

whereby your interest is to be assigned, pledged or sold, either in part or whole?

Money for this investment will be derived from the following sources: (use Attachment J, Additional Information, if more space is needed)

Percentage of ownership this amount represents: %

Yes* No If “Yes”, explain: (use Schedule J, Additional Information, if more space is needed.)

5. ANNUAL INCOME: (use Schedule J, Additional Information, if more space is needed)

Salary (Source):

Salary (Source):

Salary (Source):

Interest (Source):

Interest (Source):

Dividends (Source):

Dividends (Source):

Other (Source):

Other (Source):

Other (Source):

Other (Source):


PERSONAL FINANCIAL INFORMATION

Page 7 of 38

I, , acknowledge, understand and agree that by applying for and accepting any

license, certifi cation, registration, renewal, fi nding of suitability, or other approval (each a “License”) from the New Mexico

Gaming Control Board (“Board”), I am certifying to the Board that:

1. I have read the Gaming Control Act, Sections 60-2E-1 through 60-2E-61 NMSA 1978 (“Act”) and administrative

rules, plans and policies adopted or approved by the Board (collectively “Rules” New Mexico Administrative Code

15.1 et seq), and I understand and will implement the requirements including changes of the Act and Rules.

2. I have read the minimum internal controls established or approved by the Board for use by the gaming operator

licensee (“Licensee”) for which I am a key person, and I understand and will implement the requirements of the

minimum internal controls.

3. I have read the compulsive gambling assistance plan required by the Act and Board rules and approved by the Board

for use by the Licensee, and I understand the requirements of the compulsive gambling assistance plan.

4. I understand and agree that, as a key person, I am responsible for the Licensee’s compliance with the Act and Rules

including, where applicable to my job duties, the minimum internal controls and compulsive gambling assistance

plan. I understand that I am obligated to report any violations of the Act or Rules to the NMGCB.

5. I am signing this Certifi cation with the knowledge that the Licensee and I will be subject to disciplinary action,

including fi nes and/or revocation or suspension of the License, for failure to comply with the Act or Board rules

including, where applicable to my job duties, requirements of the minimum internal controls and compulsive

gambling assistance plan.

Page 8 of 38

CERTIFICATION

Applicant's Printed Name


State of )

)

County of )

Subscribed and sworn to before me by this day of , .

My commission expires:

Printed Full Legal Name (Last, First, Middle)Pri

Signature (Must be notarized by notary public) Date:

Notary PublicSigned:

[SEAL]

The Statutes, Rules, Act & Administrative Code, as amended and changed, can be found on our

website at www.nmgcb.org.

AFFIRMATION & CONSENT

I, _______________________________________, state under penalty of perjury that the entire Key & Affi liated Person Applica-

tion Form, statements, attachments, and supporting schedules are true and correct to the best of my knowledge and belief, and that

this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed suf-

fi cient cause for the refusal to issue a certifi cation of fi nding of suitability by the State of New Mexico. Further, I am aware that later

discovery of an omission or misrepresentation made in the above statements may be grounds for the denial or revocation of a gaming

certifi cation. I am voluntarily submitting this application to the New Mexico Gaming Control Board under oath with full knowledge

that I may be charged with perjury or other crimes for intentional omissions and misrepresentations pursuant to New Mexico law. I

further consent to any background investigation necessary to determine my present and continuing suitability and that this consent

continues as long as I hold a New Mexico Gaming certifi cation, and for 90 days following the expiration or surrender of such gam-

ing certifi cation. I also agree that the State of New Mexico, its agencies, offi cers and assigns, shall be entitled to collect from me all

expenses it incurs in processing this Key and Affi liated Application Form. If I fail to pay all the expenses incurred by the State for

processing this Key and Affi liated Application Form, I agree that the State shall be entitled to recover from me any expenses incurred

in pursuing its legal remedies, including, but not limited to, reasonable attorneys fees and costs.


Page 9 of 38


State of )

)

County of )

Subscribed and sworn to before me by this day of , .

My commission expires: Signed:

[SEAL]


Notary Public

My obligation and responsibilities under the Act and Rules continue so as long as I am in possession of a Finding of Suitability.

Further, I , affi rm that having a fi nding of suitability is a privilege and I have no property owner-

ship interest in a fi ndings of suitability.

Printed Full Legal Name

1. I/We, , hereby authorize the New Mexico Gaming Control Board or its designee

(“collectively, “Board”) to conduct a complete investigation into my/our personal background, using whatever legal means they

deem appropriate. I/We hereby waive any rights of confi dentiality in this regard.

2. I/We hereby authorize and request a review, full disclosure, and release of any and all information, materials, and documents

concerning me/us requested by the New Mexico Gaming Control Board (“Board”), its agents, or employees, whether the information,

materials, and documents are of a public, private, or confi dential nature and whether the information, materials, and documents

would otherwise be protected from disclosure by any constitutional, statutory or common law privilege.

3. I/We understand that by signing this request, a fi nancial records check will be conducted. I/We authorize any fi nancial institution,

fi nancial services company and/or credit reporting agency to release to the Board, its agents, or employees, a complete and accurate

record of my/our fi nancial transactions, including but not limited to internal banking memoranda, past and present loan applications,

checking account records, savings deposit records, safe deposit box records, securities transactions, credit reports and any other

documents relating to my/our personal or business fi nancial records in whatever form and wherever located.

4. I understand that by signing this authorization, a criminal history check will be performed. I authorize the Board to obtain, maintain,

and use from any source, any information concerning me contained in any type of criminal history record fi les, wherever located.

I understand that the criminal history record fi les contain records of arrests that may have resulted in a disposition other than a

fi nding of guilt (i.e., dismissed charges, or charges that resulted in a not guilty fi nding.) I understand that the information may

contain listings of charges that resulted in suspended imposition of sentence, even though I successfully completed the conditions

of said sentence and was discharged pursuant to law. I authorize the release of this type of information, even though this record

may be designated as “confi dential” or “nonpublic” under the provisions of state or federal law.

5. I/We authorize the Board, its agents, or employees to determine the persons or entities to whom this Request is to be

presented.

6. I/We understand that the Board, its agents, or employees will conduct a complete and comprehensive investigation to determine

the validity of all information gathered. The Board, the State of New Mexico, and the agents and employees of either, will not

be held liable for inaccurate information.

7. If this Request is not suffi cient to obtain access to certain records, I/we understand that I/we may be asked to sign another

appropriate authorization or release and that any failure to do so may be taken into consideration by the Board, its agents, or

employees in reviewing my/our application.

8. I/We understand that I/we may revoke this Request in writing at any time and that the Board, its agents, or employees may take

the revocation into consideration in reviewing my/our application.

9. Upon receipt by the Board of a written request indicating an application in another jurisdiction for a gaming related license or

permit, I/we consent to the disclosure of confi dential information compiled by the Board in connection with my Board application

to any law enforcement or any regulatory agency in that other jurisdiction, including any other state, the government of the United

States, foreign country or Indian Tribe.

10. This authorization, information in the application, and fi ngerprints will be used to check the criminal history records of the FBI.

If you believe any of the information in the FBI report is incomplete or inaccurate, you can apply to change, correct or update the

FBI identifi cation record. The procedure to do this is set forth in Title 28, C.F.R. §16.34. In the event you choose to engage in

this process, upon written notice to the Licensing Division of the NMGCB, you will be given a reasonable amount of additional

time before a decision is made concerning your application.

Page 10 of 38

APPLICANT'S INVESTIGATION AUTHORIZATION

-AND-

REQUEST TO RELEASE INFORMATION



of 38

APPLICANT'S INVESTIGATION AUTHORIZATION

-AND-REQUEST TO RELEASE INFORMATION

(continued)


11. I/We hereby release, waive, discharge, and agree to hold harmless, and otherwise waive liability as to the State of New Mexico, the

Board, and other agents or employees of the State of New Mexico for any damages resulting from any collection, use, disclosure,

or publication in any manner, other than a willfully unlawful disclosure or publication, of any material or information acquired

during inquiries, investigations, or hearings, and hereby authorize the lawful use, disclosure, or publication of this material or

information.

12. I/We do, for myself/ourselves, my/our heirs, executors, administrators, successors, and assigns, hereby release the providers of

the information collected pursuant to this Request, and their agents and employees, from any and all liability arising out of or by

reason of complying with this Request.

13. A photocopy of this Request will be considered as valid and effective as the original.

State of )

)

County of )

Subscribed and sworn to before me by and

this day of , .

My commission expires: Signed:

[SEAL]


Printed Full Legal Name (Last, First, Middle)

Spouse's Printed Full Legal Name (Last, First, Middle)

Spouse's Signature (Must be notarized by notary public) Date:

Notary Public

of 38

VERIFICATION OF FINGERPRINTS

This form is to be completed by the law enforcement agency, or upon Board approval, another entity providing the service of a

certifi ed identifi cation technician that takes your fi ngerprints.

The enclosed fi ngerprint cards contain the prints of


NAME OF APPLICANT

Name of Person Taking Fingerprints

Law Enforcement Agency Name

ORI # or Certifi cation #

Signature

Title

Date

For any question on the application for which you need additional space to provide your answer, select the appropriate Attachment from the attached set of Attachment forms. If there is not an Attachment form, please use “Attachment J, Additional Information.” If you are unsure which form applies, contact the NMGCB Licensing and Background Division for assistance.


Attachment Forms

Make as many copies of the form as are necessary to fully and completely answer the question asked or to provide the information requested.

Sign and date the bottom of each form. Please note: You are responsible for all information included on these forms, regardless of who provides the information or completes the form. Any false statements, inaccuracies or incompletenesses may have serious consequences, including the rejection of your applica-tion, and/or the denial and/or the revocation of your license(s) and/or criminal prosecution.

In the upper right hand corner of the form is a page number in the following format: “page ___ of ___ pages.” Arrange the forms for each item, or question in the appropriate order and number each form se-quentially in the first blank (“page ___”). In the second blank, on each page (“of ___ pages”) indicate the total number of forms included for that question or request for information. For example: if you attach 3 “Residence Data” forms, they would be numbered “page 1 of 3 pages”, “page 2 of 3 pages” and “page 3 of 3 pages.”

Attach all Attachment Forms to the completed Application in the order that they appear in the body of the Application and note on the checklist which Attachment Forms are attached and the number of pages included for each.

1.

2.

3.

4.

5.

Instruction Sheet

Page 13 of 38


Attachment A - Residence Data

DATES

FROM:(MO/YR)

TO:(MO/YR)

ADDRESSNAME, ADDRESS & PHONE NUMBER OF LANDLORD OR

MORTGAGE HOLDER, IF KNOWNOWN OR

RENT

Beginning with your current residence(s) and working backward, provide the following information with respect to each place where you have lived (including residences while attending college or while in military service) during the last 15 years or since the age of 18, whichever is less.


Page 14 of 38

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Attachment B - Gaming License List and History

• Do you or any member of your immediate family currently possess a New Mexico gaming license or are you an affiliated person of any other type of New Mexico gaming licensee? • Have you or any member of your immediate family ever applied for a gaming license in this or any other jurisdiction, domestic, tribal, or foreign, whether or not the license was ever issued? • Have you or your spouse ever applied for a gaming license in this or any other jurisdiction (domestic, tribal or foreign, whether or not the license was ever issued?

If you need any additional space to explain and provide any information relevant to any of the licenses or applications listed on this page, you may use ATTACHMENT J, Additional Information.

Applicant License Type Disposition Status

Jurisdiction Explanation
















Page 15 of 38

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Attachment C - Family Information

For purposes of this application, “immediate family” means: spouse, parents (including step and adoptive parents), spouses of parents, parents of spouse, siblings and their spouses, children and their spouses and anyone with whom the applicant shares a residence or domicile regardless of their relationship to the applicant.

Name Date of Birth Relation to Applicant


Name


Name


Name


Name


Name


Name


Name


Name


Name


Name


Name



Occupation

Date of Birth Relation to Applicant Occupation











Page 16 of 38

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Attachment D - Child Support Obligations

I am subject to a court order for the support of one or more children and I am in compliance with a plan approved by the public agency/court enforcing the order for the repayment of the amount owed pursuant to the order (indicate amount and attach cor-responding public agency/court documents).

I am subject to a court order for the support of one or more children and I am NOT in compliance with the order or a plan approved by the public agency/court enforcing the order for the repayment of the amount owed pursuant to the order (indicate amount past due and attach corresponding public agency/court documents).

Complete the following information for each individual child support agency responsible for the administration of a court order to which you are subject for the support of one or more children.

Identify the public agency/court response for enforcing the child support order:

Name of Child

Address of Child

Agency

Contact Person

Case/Field Number

Phone Number


Name of Child

Address of Child

Agency

Contact Person

Case/Field Number

Phone Number


Name of Child

Address of Child

Agency

Contact Person

Case/Field Number

Phone Number


Page 17 of 38

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Attachment E - Employment/Business History

List all employment (including business ownership) by the applicant. List all employment by the applicant’s spouse in the last ten (10) years and in gaming or gaming related industry employment prior to the last ten (10) years. In addition, list any and all employment in any gaming or gaming related industry by any member of the applicant’s immediate family (“immediate family” means: spouse, parents (including step and adoptive parents), spouses of parents, parents of spouse, siblings and their spouses, children and their spouses and anyone with whom the applicant shares a residence or domicile regardless of their relationship to the applicant.).

Name




Title/Position Held

Reason for Leaving

Mailing Address


Zip CodeCity State

Name




Title/Position Held

Reason for Leaving

Mailing Address


Zip CodeCity State

Name




Title/Position Held

Reason for Leaving

Mailing Address


Zip CodeCity State

Name




Title/Position Held

Reason for Leaving

Mailing Address


Zip CodeCity State

Name




Title/Position Held

Reason for Leaving

Mailing Address


Zip CodeCity State

Name




Title/Position Held

Reason for Leaving

Mailing Address


Zip CodeCity State


Page 18 of 38

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Attachment F - Professional Licenses

Please list all professional licenses for which the applicant or the applicant’s spouse have ever applied.

Type of License Date Issued Current Status

Issuing Agency Disciplinary Action


















Page 19 of 38

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Attachment G - Lawsuits, Judgements, Liens, Bankruptcy

List all lawsuits in which the applicant or the applicant’s spouse is now or has ever been named as a party (plaintiff or defendant) in either his or her individual capacity or as an agent, owner, officer, director or trustee of a business, corporation, partnership, association, trust or charitable organization. Under disposition, list any and all liens and/or charging orders resulting from the litigation, this would include any bankruptcy proceedings. List all judgments and liens currently in force against the applicant.

Caption of Suit, Bankruptcy, Judgement, Lien or any other Proceeding relevant to this area

Type of License

Issuing Agency and Location

Current Status and Disposition or other Explanation


Type of License




Type of License




Type of License




Page 20 of 38

Page of


Attachment H - Criminal History

If you answered “Yes” to any of the questions in the “Criminal History” section of the application, use this page to provide a full expla-nation of the facts and circumstances surrounding the incident in question. Indicate in the blank at the left hand side of the page, the number (from the application) of the question for which you are supplying additional information. Use a separate page for each question for which you need to provide an explanation. If you need more than one page for any one question, enter the question number on each page used and circle the word “Continued” on all pages except the last page for that question.

Question Continued


Page 21 of 38

Page of


Attachment I - Financial StatementsPlease list all assets, tangible and intangible, in which a direct or indirect interest is held by you, your spouse or your dependent children. For each line item, list both the cost of the asset and the present market values as of the date of this statement unless this cannot reasonably be done, in which case any special valuation date should be noted in the column provided. Detail each line entry on the appropriate schedule.


Please list all liabilities of you, your spouse, and your dependent children. Enter the amount as of the date of this statement. Detail each line entry on the appropriate schedule.

ASSET COST AT DATE AQUIRED OR PURCHASED (A)

CURRENT MARKET VALUE(B)

SPECIAL VALUATION DATE, IF ANY

CashOn Hand

In Bank (Schedule A)

1.

a)

b) b)Loans, Notes, and Other Receivables (Schedule B)

2.

Securities (Schedule C)

3.

Real Estate Interests (Schedule D)

4.

Cash Value Life Insurance (Schedule E)

5.

Cash Value Pension/Retirement Funds (Schedule F)

6.

Furniture and Clothing (Reasonable Estimate)

7.

Vehicles (Schedule G)

8.

Other (Schedule H)

9.

TOTAL ASSETS

LIABILTYORIGINAL AMOUNT OF LIABILTY

(C)AMOUNT OUTSTANDING

(D)

Notes Payable(Schedule I)

10.

Loans and Other Payables(Schedule J)

TaxesPayable (Schedule K)Mortgages or Liens on Real Estate (Schedule L)Loans Against Insurance/Pension (Schedule M)Other Indebtedness (Schedule N)

TOTAL LIABILITIES

NETWORTH

11.

12.

13.

14.

15.

Total Assets(From Column B) Less

Total Liabilities(From Column D)

Contingent Liabilities (Schedule O)

16.

Date of StatementPlease provide the name, address and phone number of the person completing this statement if it is completed by someone other than you. Name

AddressPhone Number

a)

b)

Page 22 of 38

Page of


Attachment J - Additional Information

For any question on the application for which you need additional space to provide your answer, select the appropriate Attach-ment form the attached set of Attachment forms. If there is not an Attachment form, use this form. (If you are unsure which form applies, contact the NMGCB Licensing and Background Division for assistance).

Make as many copies of the form as are necessary to fully and completely answer the question asked or to provide the informa-tion requested.

Sign and date the bottom of each form. Please note: You are responsible for all information included on these forms, regard-less of who provides the information or completes the form. Any false statements, inaccuracies or incompletenesses may have serious consequences, including the rejection of your application, and/or the denial and/or the revocation of your license(s) and/or criminal prosecution.

In the upper right hand corner of the form is a page number in the following format: “page ___ of ___ pages.” Arrange the forms for each item, or question in the appropriate order and number each form sequentially in the first blank (“page ___”). In the second blank, on each page (“of ___ pages”) indicate the total number of forms included for that question or request for information. For example: if you attach 3 “Residence Data” forms, they would be numbered “page 1 of 3 pages”, “page 2 of 3 pages” and “page 3 of 3 pages.”

Attach all Attachment Forms to the completed Application in the order that they appear in the body of the Application and note on the checklist which Attachment Forms are attached and the number of pages included for each.

1.

2.

3.

4.

5.

Page 23 of 38

Page of



SCHEDULE “A” - CASH IN THE BANK

List below all bank accounts (checking, savings, time deposits, certification of deposit, money market fund, etc.) foreign and domestic, maintained by you, your spouse or dependent childern. Identify with an asterick (*) any check writing accounts held with brokerage houses, insurance companies, etc.


NAME AND ADDRESS OF INSTITUTION

NAME OF PERSON(S) AND TAX IDENTIFICATION NUMBERS APPEARING ON ACCOUNT

ACCOUNT NUMBER

DATE OFBALANCE

INTERESTRATE %

BALANCE

TOTAL CURRENT BALANCE(Enter this figure in item 1b,

column B on page 22)

Page 24 of 38

TOTAL CURRENT BALANCE(Enter this figure in item 2,



SCHEDULE “B” - LOANS, NOTES AND OTHER RECEIVABLESList below all loans, notes and other receivables held by you, your spouse or your dependent children.


NAME AND ADDRESS OF DEBTOR

NATURE OF ADVANCE AND NATURE OF SECURITY, IF ANY

(INDICATE IF UNSECURED)

ORIGINAL LOAN

AMOUNTDUE DATETOTAL

PAYMENTSCURRENTBALANCE

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

INTERESTRATE %

ORIGINAL DATE OF

LOAN/NOTERECEIVABLE

TOTAL ORIGINAL LOAN AMOUNTS(Enter this figure in item 2,

column A on page 22)

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Page 25 of 38

TOTAL CURRENT MARKET VALUE(Enter this figure in item 3,



SCHEDULE “C” - SECURITIESProvide the information in the table below for all stocks, bonds, mutual funds, commodity accounts, options, warrants, etc., held or controlled by you, your spouse or dependent children in any jurisdiction. Whenever interest exists through a mutual fund or holding company, the individual stocks or bonds held by such mutual fund or holding company need not be listed. Whenever such interest exists through a beneficial interest in a trust, the securities held in such trust shall be listed if you, your spouse or your dependent children have knowledge of what securities are so held. INDICATE PUBLICLY TRADED SECURITIES BY AN ASTERISK (*).


NUMBER OF SECURITIES OR CONTRACTS HELD

DATE OF

VALUATION

NAME OF ISSUING COM-PANY OR GOVERNMENT

AGENCY/ORGANIZATION

REGISTERED OWNER

DATE OF AND PRICE AT

PURCHASE

CURRENTMARKET VALUE

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

TYPE OF SECURITIES

MARKET VALUE AT TIME OF

ACQUISTION

TOTAL PURCHASE PRICE(Enter this figure in item 3,

column A on page 22)

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

% OF OWN-ERSHIP IF GREATER THAN 5%

Page 26 of 38

TOTAL CURRENT MARKET VALUE(Enter this figure in item 4, column B on

page 22)


SCHEDULE “D” - REAL ESTATE INTERESTSIndicate below the location, size, general nature, acquistion date and other information requested regarding any real property in any jurisdiction in which any direct, indirect, vested or con-tingent interest is held by you, your spouse or dependent children, along with the names of all the individuals or entities who share a direct, indirect, vested or contingent interest therein.


ADDRESS PARCEL/LOT NUMBER

MONTHLY RENTAL INCOME, IF ANY

TYPE OF PROPERTY

PURCHASE PRICE OF %

OWNED

DATE OF AND PRICE AT

PURCHASE

ESTIMATEDMARKET VALUE

OF % OWNED

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

LOT SIZE STAND NO./SQUARE FOOTAGE OF

BUILDING

DATE ACQUIRED/DOWN PAYMENT

TOTAL PUR-CHASE PRICE(Enter this fig-ure in item 4, column A on

page 22)

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

INDIVIDUALS OR ENTITIES SHARING INTEREST (INCLUDE % OF OWNERSHIP FOR EACH)

Page 27 of 38

TOTAL CASH SURRENDER VALUE (Enter this figure in item 5,



SCHEDULE “E” - CASH VALUE - LIFE INSURANCEIndicate below the information requested with regard to the cash value of all life insurance policies held by you, your spouse or your dependent children.


DATE PURCHASED BENEFICIARY(IES)ANNUAL PREMIUM

PAYMENTS

EFFECTIVE DATE OF CASH SURRENDER

VALUE

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

INSURANCE CARRIER POLICY NUMBER FACE VALUE

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

CASH SURRENDER VALUE

Page 28 of 38

TOTAL CURRENT CASH VALUE (Enter

this figure in item 6, column B on page 22)


SCHEDULE “F” - CASH VALUE - PENSION/RETIREMENT FUNDS


TYPE OF FUND EMPLOYER/INSTITUTIONCUMULATIVE

EMPLOYER CONTRIBUTION

EFFECTIVE DATE OF CASH VALUE

CHECK IFHELD BYSPOUSE

TYPE OF SECURITIES HELD AND ACCOUNT

NUMBER , IF ANY

CUMULATIVE EMPLOYEE

CONTRIBUTION

Spouse

Spouse

Spouse

Spouse

Spouse

CURRENT CASH VALUE

TOTAL CUMULATIVE EMPLOYEE ONTRIBUTION

(Enter this figure in item 6, column A on page 22)

Indicate below the information requested with regard to the cash value of all retirement/investment/pension funds* held by you or your spouse.

*If you are filing this application in the United States, the information shall include IRA, 401 K and KEOGH plans.

Page 29 of 38

TOTAL CURRENT CASH VALUE (Enter this figure in item 8,



SCHEDULE “G” - VEHICLES


TYPE OF VEHICLE DATE OF PURCHASE/LEASE

MAKE/MODEL OF VEHICLE

IF OWNED, CUR-RENT MARKET

VALUE

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

SPECIFY IF OWNED OR LEASED*

MODEL YEAR COST**

TOTAL COST OF VEHICLES (Enter this figure in item 8, column

A on page 22)

Indicate below the information requested with regard to all vehicles owned or leased by you, your spouse or your dependent children.

*If leased, specify in this column the length of the lease, total lease costs, down payments, monthly payments and number of payments over the life of the lease.

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Owned

Leased

**If leased, enter the sum of the down payment plus monthly payments to date as the total cost.

Owned

Leased

Owned

Leased

Owned

Leased

Owned

Leased

Page 30 of 38

TOTAL CURRENT MARKET VAL-UE OF OTHER ASSETS (Enter this

figure in item 9, column B on page 22)


SCHEDULE “H” - OTHER ASSETS


NATURE OF ASSETDATE OF

ACQUISTIONDATE OF

VALUATIONCURRENT

MARKET VALUE

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

% OF OWNERSHIP INTEREST

COST

TOTAL COST(S) OF OTHER ASSETS (Enter this figure in item 9, column A

on page 22)

List below the information requested regarding all other assets, including any business investments in which any direct, indirect, vested or contingent is held by you, your spouse or your dependent children. Business interests should include, but not be limited to, joint ventures, partnerships, sole proprietorships, corportations and LLCs. Other assets should include, but not be limited to, art collections, coin collections and antiques.

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Page 31 of 38

TOTAL AMOUNT OF OUTSTANDING NOTES

PAYABLE (Enter this figure in item 10, column D on

page 22)


NAME AND ADDRESS OF CREDITOR

ORIGINAL AMOUNT OF NOTE

DATE INCURRED

AMOUNT OF PERIODIC PAYMENT/

PAY PERIOD

INTEREST RATE (%)

NATURE OF SECURITY,

IF ANY

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

ACCOUNT NUMBER, IF

ANYDUE DATE

TOTAL ORIGINAL AMOUNTS OF NOTES PAYABLE (Enter

this figure in item 10, column C on page 22)

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild


SCHEDULE “I” - NOTES PAYABLEList below the information requested with regard to all notes payable for which you, your spouse or your dependent children are obligated.

TOTAL PAYMENTS

OUTSTANDING AMOUNT OF

LIABILITY

Page 32 of 38



ORIGINAL AMOUNT

OF LIABILITY

DATE OPENED ORINCURRED

NATURE OF ACCOUNT

INTEREST RATE (%)

NATURE OF SECURITY,

IF ANY

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

ACCOUNT NUMBER, IF

ANY

DUE DATE

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild


SCHEDULE “J” - LOANS AND OTHER PAYABLESList below the information requested with regard to all accounts payable (including lines of credit, installment loans, revolving charge accounts and any other accounts) for which you, your spouse or your dependent children are obligated.

TOTAL PAYMENTS

CURRENT AMOUNT OUTSTANDING

TOTAL AMOUNT OF OUT-STANDING LOANS AND OTHER PAYABLE (Enter

this figure in item 11, column D on page 22)

TOTAL ORIGINAL AMOUNTS OF LIABILITY (Enter this figure in item 11, column C on page 22)

Page 33 of 38

TOTAL AMOUNT OF TAXES PAYABLE (Enter this figure in item

12, column D on page 22)


TAXING AUTHORITY DATE AND AMOUNT OF ORIGINAL OBLIGATION

FINES, PENALTIES AND INTEREST, IF ANY

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

NATURE OF TAX

TOTAL ORIGINAL TAX OBLIGA-TIONS (Enter this figure in item 12,

column C on page 22)

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild


SCHEDULE “K” - TAXESList below the information requested with regard to all taxes payable for which you, your spouse, or your dependent children are obligated. Only real estate and income taxes need to be included.

TOTAL AMOUNT DUE

Page 34 of 38


NAME AND ADDRESS OF MORTGAGEE OR

LIEN HOLDER

ORIGINAL AMOUNT OF

LIABILITY

DATEINCURRED

DESCRIPTION/ADDRESS OF REAL ESTATE

TERMS OF MORTGAGE/

INTEREST RATE (%)

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

ACCOUNT NUMBER

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild


SCHEDULE “L” - MORTGAGES OR LIENS PAYABLE ON REAL ESTATEList below the information requested with regard to all mortgages or liens due and owing on real estate for which you, your spouse or your dependent children are obligated.

AMOUNT OF PERIODIC

PAYMENT/PAY PERIOD

CURRENT MORTGAGE

BALANCE

TOTAL MORTGAGES OR LIENS PAYABLE ON REAL ESTATE

(Enter this figure in item 13, column D on page 22)

TOTAL ORIGINAL MORTGAGES OR LIENS PAYABLE ON REAL ESTATE (Enter this figure in item

13, column C on page 22)

Page 35 of 38

TOTAL AMOUNT OUTSTANDING INSURANCE/PENSION LOANS

(Enter this figure in item 14, column D on page 22)


ORIGINAL AMOUNT OF LOAN

INTEREST RATE

(%)

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

PURPOSE OF LOAN

TOTAL ORIGINAL LIABILITY INSURANCE/PENSION LOANS (Enter this figure in item 14,

column C on page 22)

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild


SCHEDULE “M” - LOANS AGAINST INSURANCE/PENSION PLANSList below the information requested with regard to all loans against life insurance policies, pension plans, etc., taken by you, your spouse or your dependent children.

CURRENT LOAN BALANNCE

INSURANCE CARRIER/PENSION PLAN

DATE OF

LOAN

PERIODIC PAYMENT AMOUNT/

PAY PERIOD

Page 36 of 38

TOTAL AMOUNT OUTSTANDING

OTHER INDEBT-EDNESS (Enter this figure in item 15, col-umn D on page 22)


SCHEDULE “N” - ANY OTHER INDEBTEDNESS



DISCRIPTION OF LIABILITY, TYPE OF OBLIGATION AND

NATURE OF SECURITY, IF ANY

AMOUNT OF PERIODIC PAYMENT/

PAY PERIOD

OUTSTANDING AMOUNT OF

INDEBTEDNESS

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

INTEREST RATE

(%)

DUE DATE

ORIGINAL AMOUNT OF LIABILITY

TOTAL ORIGINAL AMOUNT OTHER IN-DEBTEDNESS (Enter this figure in item 15, column C on page 22)

Indicate below the information requested with regard to any other indebtedness for which you, your spouse or your dependent children are obligated.

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

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TOTAL AMOUNT OUTSTANDING CONTINGENT

LIABILITIES (Enter this figure in item 16,

column D on page 22)


SCHEDULE “O” - CONTINGENT LIABILITIES


NAME AND ADDRESS OF CONTIN-

GENT CREDITORACCOUNT NUMBER

DESCRIPTION OF OBLIGATION INCLUDING NATURE OF

SECURITY, IF ANY

CURRENT AMOUNT OF CONTINGENT

OBLIGATIONS

CHECK IFHELD BY

SPOUSE ORDEPENDENT

CHILD

DATE INCURRED

PRIMARY DEBTOR

ORIGINAL AMOUNT OF CONTINGENT

OBLIGATION

TOTAL ORIGINAL CONTINGENT LI-

ABILITIES (Enter this figure in item 16, column

C on page 22)

Indicate below the information requested with regard to all contingent liabilities for which you, your spouse or you dependent children are obligated.

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Spouse

DependentChild

Page 38 of 38

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