Federal Trade Commission v. IAB Marketing Associates, LP

Filing 72

PRELIMINARY INJUNCTION. Signed by Judge Robert N. Scola, Jr. on 10/9/2012. (Attachments: # 1 Financial Statement - Individual Defendant, # 2 Financial Statement - Corporate Defendant, # 3 Consent to Release of Financial Records) (rss)

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FEDERAL TRADE COMMISSION FINANCIAL STATEMENT OF INDIVIDUAL DEFENDANT Instructions: 1. Complete all items. Enter “None” or “N/A” (“Not Applicable”) where appropriate. If you cannot fully answer a question, explain why. 2. The font size within each field will adjust automatically as you type to accommodate longer responses. 3. “Dependents” include your live-in companion, dependent children, or any other person, whom you or your spouse (or your children’s other parent) claimed or could have claimed as a dependent for tax purposes at any time during the past five years. 4. “Assets” and “Liabilities” include ALL assets and liabilities, located within the United States or elsewhere, whether held individually or jointly. 5. Attach continuation pages as needed. On the financial statement, state next to the Item number that the Item is being continued. On the continuation page(s), identify the Item number(s) being continued. 6. Type or print legibly. 7. Initial each page in the space provided in the lower right corner. 8. Sign and date the completed financial statement on the last page. Penalty for False Information: Federal law provides that any person may be imprisoned for not more than five years, fined, or both, if such person: (1) “in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry” (18 U.S.C. § 1001); (2) “in any . . . statement under penalty of perjury as permitted under section 1746 of title 28, United States Code, willfully subscribes as true any material matter which he does not believe to be true” (18 U.S.C. § 1621); or (3) “in any (. . . statement under penalty of perjury as permitted under section 1746 of title 28, United States Code) in any proceeding before or ancillary to any court or grand jury of the United States knowingly makes any false material declaration or makes or uses any other information . . . knowing the same to contain any false material declaration” (18 U.S.C. § 1623). For a felony conviction under the provisions cited above, federal law provides that the fine may be not more than the greater of (i) $250,000 for an individual or $500,000 for a corporation, or (ii) if the felony results in pecuniary gain to any person or pecuniary loss to any person other than the defendant, the greater of twice the gross gain or twice the gross loss. 18 U.S.C. § 3571. Attachment A BACKGROUND INFORMATION Item 1. Information About You Your Full Name ______________________________________________ Social Security No. ___________________ Place of Birth _________________________ Date of Birth _______________ Drivers License No. _______________ Current Address ______________________________________________________ From (Date) _________________ Rent or Own? _________ Telephone No. _________________________ Facsimile No. _________________________ E-Mail Address _____________________________________ Internet Home Page ____________________________ Previous Addresses for past five years: Address___________________________________________ Rent or Own?________ From/Until_________________ Address___________________________________________ Rent or Own?________ From/Until_________________ Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they were used________________________________________________________________________________________ Item 2. Information About Your Spouse or Live-In Companion Spouse/Companion's Name _____________________________________ Social Security No. ___________________ Place of Birth _________________________________________ Date of Birth _______________________________ Identify any other name(s) and/or social security number(s) your spouse/companion has used, and the time period(s) during which they were used ________________________________________________________________________ Address (if different from yours) _____________________________________________________________________ From (Date) _________________________ Rent or Own?___________ Telephone No._________________________ Employer’s Name and Address ______________________________________________________________________ Job Title _______________________ Years in Present Job _________ Annual Gross Salary/Wages $______________ Item 3. Information About Your Previous Spouse Previous Spouse’s Name & Address __________________________________________________________________ ___________________________________ Social Security No. _________________ Date of Birth _______________ Page 2 Attachment A Initials __________ Item 4. Contact Information Name & Address of Nearest Living Relative or Friend ___________________________________________________ ____________________________________________________________ Telephone No. ______________________ Item 5. Information About Dependents Who Live With You <Name ______________________________________________ Date of Birth ________________________________ Relationship _________________________________________ Social Security No. ____________________________ <Name ______________________________________________ Date of Birth ________________________________ Relationship _________________________________________ Social Security No. ____________________________ <Name ______________________________________________ Date of Birth ________________________________ Relationship _________________________________________ Social Security No. ____________________________ Item 6. Information About Dependents Who Do Not Live With You <Name & Address ________________________________________________________________________________ Date of Birth __________________ Relationship ____________________ Social Security No.___________________ <Name Address __________________________________________________________________________________ Date of Birth __________________ Relationship ____________________ Social Security No.__________________ <Name & Address ________________________________________________________________________________ Date of Birth __________________ Relationship ____________________ Social Security No.__________________ Item 7. Employment Information Provide the following information for this year-to-date and for each of the previous five full years, for each company of which you were a director, officer, employee, agent, contractor, participant or consultant at any time during that period. “Income” includes, but is not limited to, any salary, commissions, draws, consulting fees, loans, loan payments, dividends, royalties or other benefits for which you did not pay (e.g., health insurance premiums, automobile lease or loan payments) received by you or anyone else on your behalf. <Company Name & Address ________________________________________________________________________ Dates Employed: From (Month/Year) ________________________ To (Month/Year) _________________________ Positions Held with Beginning and Ending Dates ________________________________________________________ ________________________________________________________________________________________________ Page 3 Attachment A Initials __________ Item 7. continued Income Received: This year-to-date: $______________________ _______: $______________________ 20_____: $______________________ _______: $______________________ _______: $______________________ _______: $______________________ <Company Name & Address ________________________________________________________________________ Dates Employed: From (Month/Year) ________________________ To (Month/Year) _________________________ Positions Held with Beginning and Ending Dates ________________________________________________________ ________________________________________________________________________________________________ Income Received: This year-to-date: $______________________ _______: $______________________ 20_____: $______________________ _______: $______________________ _______: $______________________ _______: $______________________ <Company Name & Address ________________________________________________________________________ Dates Employed: From (Month/Year) ________________________ To (Month/Year) _________________________ Positions Held with Beginning and Ending Dates ________________________________________________________ ________________________________________________________________________________________________ Income Received: This year-to-date: $______________________ _______: $______________________ 20_____: $______________________ _______: $______________________ _______: $______________________ _______: $______________________ Item 8. Pending Lawsuits Filed by You or Your Spouse List all pending lawsuits that have been filed by you or your spouse in court or before an administrative agency. (List lawsuits that resulted in final judgments or settlements in Items 16 and 25). Opposing Party’s Name & Address ___________________________________________________________________ Court’s Name & Address ___________________________________________________________________________ Docket No. _________________ Relief Requested ____________________ Nature of Lawsuit ___________________ ____________________________________ Status ______________________________________________________ Page 4 Attachment A Initials __________ Item 9. Pending Lawsuits Filed Against You or Your Spouse List all pending lawsuits that have been filed against you or your spouse in court or before an administrative agency. (List lawsuits that resulted in final judgments or settlements in Items 16 and 25). Opposing Party’s Name & Address ___________________________________________________________________ Court’s Name & Address ___________________________________________________________________________ Docket No. _________________ Relief Requested ____________________ Nature of Lawsuit ___________________ ____________________________________ Status ______________________________________________________ Item 10. Safe Deposit Boxes List all safe deposit boxes, located within the United States or elsewhere, held by you, your spouse, or any of your dependents, or held by others for the benefit of you, your spouse, or any of your dependents. On a separate page, describe the contents of each box. Owner’s Name Name & Address of Depository Institution Box No. __________________ ___________________________________________________________________ _________ __________________ ___________________________________________________________________ _________ __________________ ___________________________________________________________________ _________ Item 11. Business Interests List all businesses for which you, your spouse, or your dependents are an officer or director. <Business’ Name & Address ________________________________________________________________________ Business Format (e.g., corporation) __________________________ Description of Business _____________________ ______________________________ Position(s) Held, and By Whom _______________________________________ <Business’ Name & Address ________________________________________________________________________ Business Format (e.g., corporation) __________________________ Description of Business _____________________ ______________________________ Position(s) Held, and By Whom _______________________________________ <Business’ Name & Address ________________________________________________________________________ Business Format (e.g., corporation) __________________________ Description of Business _____________________ ______________________________ Position(s) Held, and By Whom _______________________________________ Page 5 Attachment A Initials __________ FINANCIAL INFORMATION: ASSETS AND LIABILITIES REMINDER: “Assets” and “Liabilities” include ALL assets and liabilities, located within the United States or elsewhere, whether held individually or jointly. Item 12. Cash, Bank, and Money Market Accounts List cash and all bank and money market accounts, including but not limited to, checking accounts, savings accounts, and certificates of deposit, held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. The term “cash” includes currency and uncashed checks. Cash on Hand $____________________________ Cash Held For Your Benefit $____________________________ Name on Account Name & Address of Financial Institution Account No. Current Balance _________________ __________________________________________________ _______________ $__________ _________________ __________________________________________________ _______________ $__________ _________________ __________________________________________________ _______________ $__________ _________________ __________________________________________________ _______________ $__________ _________________ __________________________________________________ _______________ $__________ _________________ __________________________________________________ _______________ $__________ Item 13. U.S. Government Securities List all U.S. Government securities, including but not limited to, savings bonds, treasury bills, and treasury notes, held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. Name on Account Type of Obligation Security Amount Maturity Date ____________________ _____________________________________________ $________________ _____________ ____________________ _____________________________________________ $________________ _____________ ____________________ _____________________________________________ $________________ _____________ Page 6 Attachment A Initials __________ Item 14. Publicly Traded Securities and Loans Secured by Them List all publicly traded securities, including but not limited to, stocks, stock options, registered and bearer bonds, state and municipal bonds, and mutual funds, held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. <Issuer _______________________________ Type of Security ___________________ No. of Units Owned ________ Name on Security _________________ Current Fair Market Value $_________ Loan(s) Against Security $_________ Broker House, Address _______________________________________________ Broker Account No. ____________ <Issuer _______________________________ Type of Security ___________________ No. of Units Owned ________ Name on Security _________________ Current Fair Market Value $_________ Loan(s) Against Security $_________ Broker House, Address _______________________________________________ Broker Account No. ____________ Item 15. Other Business Interests List all other business interests, including but not limited to, non-public corporations, subchapter-S corporations, limited liability corporations (“LLCs”), general or limited partnership interests, joint ventures, sole proprietorships, and oil and mineral leases, held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. <Business Format _____________________________ Business’ Name & Address ______________________________ _________________________________________________________________________ Ownership % ___________ Owner (e.g., self, spouse) ________________________________ Current Fair Market Value $____________________ <Business Format _____________________________ Business’ Name & Address ______________________________ _________________________________________________________________________ Ownership % ___________ Owner (e.g., self, spouse) ________________________________ Current Fair Market Value $____________________ Item 16. Monetary Judgments or Settlements Owed to You, Your Spouse, or Your Dependents List all monetary judgments or settlements owed to you, your spouse, or your dependents. <Opposing Party’s Name & Address __________________________________________________________________ Court’s Name & Address __________________________________________________ Docket No. _______________ Nature of Lawsuit ______________________________ Date of Judgment _______________ Amount $____________ <Opposing Party’s Name & Address __________________________________________________________________ Court’s Name & Address __________________________________________________ Docket No. _______________ Nature of Lawsuit ______________________________ Date of Judgment _______________ Amount $____________ Page 7 Attachment A Initials __________ Item 17. Other Amounts Owed to You, Your Spouse, or Your Dependents List all other amounts owed to you, your spouse, or your dependents. Debtor’s Name, Address, & Telephone No. ____________________________________________________________ Original Amount Owed $_____________ Current Amount Owed $____________ Monthly Payment $_____________ Item 18. Life Insurance Policies List all life insurance policies held by you, your spouse, or your dependents. <Insurance Company’s Name, Address, & Telephone No. _________________________________________________ ________________________________________________________________________________________________ Insured ________________________ Beneficiary _______________________ Face Value $_____________________ Policy No. _________________ Loans Against Policy $________________ Surrender Value $___________________ <Insurance Company’s Name, Address, & Telephone No. _________________________________________________ ________________________________________________________________________________________________ Insured ________________________ Beneficiary _______________________ Face Value $_____________________ Policy No. _________________ Loans Against Policy $________________ Surrender Value $___________________ Item 19. Deferred Income Arrangements List all deferred income arrangements, including but not limited to, deferred annuities, pensions plans, profit-sharing plans, 401(k) plans, IRAs, Keoghs, and other retirement accounts, held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. <Name on Account _________________________ Type of Plan ___________________ Date Established __________ Trustee or Administrator’s Name, Address & Telephone No. _______________________________________________ ________________________________________________________________________________________________ Account No. ______________________ Surrender Value $___________________ <Name on Account _________________________ Type of Plan ___________________ Date Established __________ Trustee or Administrator’s Name, Address & Telephone No. _______________________________________________ ________________________________________________________________________________________________ Account No. ______________________ Surrender Value $___________________ Page 8 Attachment A Initials __________ Item 20. Personal Property List all personal property, by category, whether held for personal use or for investment, including but not limited to, furniture and household goods of value, computer equipment, electronics, coins, stamps, artwork, gemstones, jewelry, bullion, other collectibles, copyrights, patents, and other intellectual property, held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. Property Category (e.g., artwork, jewelry) Name of Owner Property Location Acquisition Cost Current Value ____________________________ __________________ ___________________________ $_________ $__________ ____________________________ __________________ ___________________________ $_________ $__________ ____________________________ __________________ ___________________________ $_________ $__________ ____________________________ __________________ ___________________________ $_________ $__________ ____________________________ __________________ ___________________________ $_________ $__________ ____________________________ __________________ ___________________________ $_________ $__________ Item 21. Cars, Trucks, Motorcycles, Boats, Airplanes, and Other Vehicles List all cars, trucks, motorcycles, boats, airplanes, and other vehicles owned or operated by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. <Vehicle Type __________________ Make ____________________ Model ______________________ Year _______ Registered Owner’s Name __________________________ Registration State & No. ___________________________ Address of Vehicle’s Location _______________________________________________________________________ Purchase Price $_______________Current Value $_______________ Account/Loan No. ________________________ Lender’s Name and Address _________________________________________________________________________ Original Loan Amount $______________ Current Loan Balance $______________ Monthly Payment $____________ <Vehicle Type __________________ Make ____________________ Model ______________________ Year _______ Registered Owner’s Name __________________________ Registration State & No. ___________________________ Address of Vehicle’s Location _______________________________________________________________________ Purchase Price $_______________Current Value $_______________ Account/Loan No. ________________________ Lender’s Name and Address _________________________________________________________________________ Original Loan Amount $______________ Current Loan Balance $______________ Monthly Payment $____________ Page 9 Attachment A Initials __________ Item 21. Continued <Vehicle Type __________________ Make ____________________ Model ______________________ Year _______ Registered Owner’s Name __________________________ Registration State & No. ___________________________ Address of Vehicle’s Location _______________________________________________________________________ Purchase Price $_______________Current Value $_______________ Account/Loan No. ________________________ Lender’s Name and Address _________________________________________________________________________ Original Loan Amount $______________ Current Loan Balance $______________ Monthly Payment $____________ Item 22. Real Property List all real estate held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents. <Type of Property________________________________ Property’s Location_________________________________ Name(s) on Title and Ownership Percentages___________________________________________________________ Acquisition Date________________ Purchase Price $____________________ Current Value $___________________ Basis of Valuation_______________________________________ Loan or Account No._________________________ Lender’s Name and Address_________________________________________________________________________ Current Balance On First Mortgage $__________________ Monthly Payment $_________________ Other Loan(s) (describe)____________________________________________ Current Balance $_________________ Monthly Payment $__________________ Rental Unit?_________________ Monthly Rent Received $_____________ <Type of Property________________________________ Property’s Location_________________________________ Name(s) on Title and Ownership Percentages___________________________________________________________ Acquisition Date________________ Purchase Price $____________________ Current Value $___________________ Basis of Valuation_______________________________________ Loan or Account No._________________________ Lender’s Name and Address__________________________________________________________________________ Current Balance On First Mortgage $__________________ Monthly Payment $_________________ Other Loan(s) (describe)____________________________________________ Current Balance $_________________ Monthly Payment $__________________ Rental Unit?_________________ Monthly Rent Received $_____________ Page 10 Attachment A Initials __________ Item 23. Credit Cards List each credit card held by you, your spouse, or your dependents. Also list any other credit cards that you, your spouse, or your dependents use. Name of Credit Card (e.g., Visa, MasterCard, Department Store) Account No. Name(s) on Account Current Balance Minimum Monthly Payment ____________________________ __________________ _________________ $____________ $________________ ____________________________ __________________ _________________ $____________ $________________ ____________________________ __________________ _________________ $____________ $________________ ____________________________ __________________ _________________ $____________ $________________ ____________________________ __________________ _________________ $____________ $________________ ____________________________ __________________ _________________ $____________ $________________ Item 24. Taxes Payable List all taxes, such as income taxes or real estate taxes, owed by you, your spouse, or your dependants. Type of Tax Amount Owed Year Incurred _______________________________ $__________________________ ___________________ _______________________________ $__________________________ ___________________ _______________________________ $__________________________ ___________________ _______________________________ $__________________________ ___________________ Item 25. Judgments or Settlements Owed List all judgments or settlements owed by you, your spouse, or your dependents. Opposing Party’s Name & Address___________________________________________________________________ Court’s Name & Address____________________________________________________ Docket No._____________ Nature of Lawsuit_______________________________________ Date______________ Amount $______________ Page 11 Attachment A Initials __________ Item 26. Other Loans and Liabilities List all other loans or liabilities in your, your spouse's, or your dependents’ names. <Name & Address of Lender/Creditor _________________________________________________________________ Nature of Liability_____________________________________ Name(s) on Liability__________________________ Date of Liability___________________ Amount Borrowed $________________ Current Balance $_______________ Payment Amount $_____________________ Frequency of Payment_____________________ <Name & Address of Lender/Creditor _________________________________________________________________ Nature of Liability_____________________________________ Name(s) on Liability__________________________ Date of Liability___________________ Amount Borrowed $________________ Current Balance $_______________ Payment Amount $_____________________ Frequency of Payment_____________________ OTHER FINANCIAL INFORMATION Item 27. Tax Returns List all federal tax returns that were filed during the last three years by or on behalf of you, your spouse, or your dependents. Provide a copy of each signed tax return that was filed during the last three years. Tax Year Name(s) on Return Refund Expected ___________ ___________________________________________________________________ $_______________ ___________ ___________________________________________________________________ $_______________ ___________ ___________________________________________________________________ $_______________ Item 28. Applications for Credit List all applications for bank loans or other extensions of credit that you, your spouse, or your dependents have submitted within the last two years. Provide a copy of each application, including all attachments. Name(s) on Application Name & Address of Lender _________________________________ ______________________________________________________________ _________________________________ ______________________________________________________________ _________________________________ ______________________________________________________________ Page 12 Attachment A Initials __________ Item 29. Trusts and Escrows List all funds or other assets that are being held in trust or escrow by any person or entity for you, your spouse, or your dependents. Also list all funds or other assets that are being held in trust or escrow by you, your spouse, or your dependents, for any person or entity. Provide copies of all executed trust documents. Trustee or Escrow Agent’s Name & Address Date Established Grantor Beneficiaries Present Market Value of Assets ________________________________ ______________ _________________ ______________ $______________ ________________________________ ______________ _________________ ______________ $______________ ________________________________ ______________ _________________ ______________ $______________ ________________________________ ______________ _________________ ______________ $______________ ________________________________ ______________ _________________ ______________ $______________ Item 30. Transfers of Assets List each person to whom you have transferred, in the aggregate, more than $2,500 in funds or other assets during the previous three years by loan, gift, sale, or other transfer. For each such person, state the total amount transferred during that period. Transferee’s Name, Address, & Relationship Property Transferred Aggregate Value Transfer Date Type of Transfer (e.g., Loan, Gift) ______________________________________ ________________ $____________ __________ _________________ ______________________________________ ________________ $____________ __________ _________________ ______________________________________ ________________ $____________ __________ _________________ ______________________________________ ________________ $____________ __________ _________________ ______________________________________ ________________ $____________ __________ _________________ ______________________________________ ________________ $____________ __________ _________________ ______________________________________ ________________ $____________ __________ _________________ Page 13 Attachment A Initials __________ SUMMARY FINANCIAL SCHEDULES Item 31. Combined Balance Sheet for You, Your Spouse, and Your Dependents ASSETS Cash on Hand (Item 12) LIABILITIES $___________ Credit Cards (Item 23) $____________ Cash in Financial Institutions (Item 12) $___________ Motor Vehicles - Liens (Item 21) $____________ U.S. Government Securities (Item 13) $___________ Real Property - Encumbrances (Item 22) $____________ Publicly Traded Securities (Item 14) $___________ Loans Against Publicly Traded Securities (Item 14) $____________ Other Business Interests (Item 15) $___________ Taxes Payable (Item 24) $____________ Judgments or Settlements Owed to You (Item 16) $___________ Judgments or Settlements Owed (Item 25) $____________ Other Amounts Owed to You (Item 17) $___________ Other Loans and Liabilities (Item 26) $____________ Surrender Value of Life Insurance (Item 18) $___________ Other Liabilities (Itemize) Deferred Income Arrangements (Item 19) $___________ _________________________________ $____________ Personal Property (Item 20) $___________ _________________________________ $____________ Motor Vehicles (Item 21) $___________ _________________________________ $____________ Real Property (Item 22) $___________ _________________________________ $____________ _________________________________ $____________ Other Assets (Itemize) ___________________________ $___________ _________________________________ $____________ ___________________________ $___________ _________________________________ $____________ ___________________________ $___________ _________________________________ $____________ ___________________________ $___________ _________________________________ $____________ Total Assets $ Total Liabilities $ Page 14 Attachment A Initials __________ Item 32. Combined Average Monthly Income and Expenses for You, Your Spouse, and Your Dependents for the Last 6 Months Provide the average monthly income and expenses for you, your spouse, and your dependents for the last 6 months. Do not include credit card payments separately; rather, include credit card expenditures in the appropriate categories. INCOME Salary - After Taxes EXPENSES $___________ Mortgage Payments for Residence(s) $____________ Fees, Commissions, and Royalties $___________ Property Taxes for Residence(s) $____________ Interest $___________ Rental Property Expenses, Including Mortgage Payments, Taxes, and Insurance $____________ Dividends and Capital Gains $___________ Car or Other Vehicle Lease or Loan Payments $____________ Gross Rental Income $___________ Food Expenses $____________ Profits from Sole Proprietorships $___________ Clothing Expenses $____________ Distributions from Partnerships, S-Corporations, and LLCs $___________ Utilities $____________ Distributions from Trusts and Estates $___________ Medical Expenses, Including Insurance $____________ Distributions from Deferred Income Arrangements $___________ Other Insurance Premiums $____________ Social Security Payments $___________ Other Transportation Expenses $____________ Alimony/Child Support Received $___________ Other Household Expenses $____________ Gambling Income $___________ Other Income (Itemize) Other Expenses (Itemize) _________________________________ $____________ ___________________________ $___________ _________________________________ $____________ ___________________________ $___________ _________________________________ $____________ ___________________________ $___________ _________________________________ $____________ Total Income $ Total Expenses $ Page 15 Attachment A Initials __________ ATTACHMENTS Item 33. Documents Attached to this Financial Statement List all documents that are being submitted with this financial statement. Item No. Document Relates To Description of Document ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ ___________________ ______________________________________________________________________________ I am submitting this financial statement with the understanding that it may affect action by the Federal Trade Commission or a federal court. I have used my best efforts to obtain the information requested in this statement. The responses I have provided to the items above are true and contain all the requested facts and information of which I have notice or knowledge. I have provided all requested documents in my custody, possession, or control. I know of the penalties for false statements under 18 U.S.C. § 1001, 18 U.S.C. § 1621, and 18 U.S.C. § 1623 (five years imprisonment and/or fines). I certify under penalty of perjury under the laws of the United States that the foregoing is true and correct. Executed on: ______________________________ (Date) Page 16 _____________________________________________________ Signature Attachment A Initials __________

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