Federal Trade Commission v. Prime Legal Plans LLC et al

Filing 67

PRELIMINARY INJUNCTION and order continuing asset freeze and other provisions of the Temporary Restraining Order, appointing a permanent receiver, and permitting expedited discovery. Signed by Judge Robert N. Scola, Jr. on 10/12/2012. (rss) (Additional attachment(s) added on 10/12/2012: # 1 Attachment A, # 2 Attachment B, # 3 Attachment C) (wc).

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 __________