United States of America v. Frederick

Filing 10

ORDER granting 7 Motion for supplementary proceedings. The defendant, Mark A. Frederick, shall appear before the undersigned in Courtroom 2, 593 Federal Building, 100 Centennial Mall North, Lincoln, Nebraska 68508 on January 27, 2011 at 1:00 p.m. to participate in a debtor's examination. Ordered by Magistrate Judge Cheryl R. Zwart. (CRZ)

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEBRASKA UNITED STATES OF AMERICA, Plaintiff, v. MARK A. FREDERICK, Defendant. IT IS ORDERED: 1) The government's motion for supplementary proceedings, (filing no. 7), is granted; and a. The defendant, Mark A. Frederick, shall appear before the undersigned in Courtroom 2, 593 Federal Building, 100 Centennial Mall North, Lincoln, Nebraska 68508 on January 27, 2011 at 1:00 p.m. to participate in a debtor's examination. At the debtor's examination, Mark Frederick will be required to answer questions concerning his/her assets, income. The defendant, Mark A. Frederick, shall complete and sign the attached financial statement and shall bring the completed financial statement, and all items listed on Attachment A, to the debtor's examination on January 27, 2011. ) ) ) ) ) ) ) ) )

4:08CV3226

MEMORANDUM AND ORDER

b.

2)

The clerk shall serve a copy of this order on the defendant, Mark Frederick.

DATED this 14th day of December, 2010. BY THE COURT: s/ Cheryl R. Zwart United States Magistrate Judge

U.S. Department of Justice Financial Statement of Debtor ( S u b m itte d for Government Action on Claims Due the United States) N O T E : Use additional sheets where space on this form is insufficient or continue on back of last page. FINANCIAL STATEMENT OF DEBTOR Authority for the solicitation of the requested information is one or more of the following: 5 U.S.C. 301, 901 (see Note, Executive Order 6166, June 10, 1933); 28 U.S.C. 501, et seq.; 31 U.S.C. 951, et seq.; 44 CFR 3101; 4 CFR 101, et seq.; 28 CFR 0.160, 0.171 and Appendix to Subpart Y. Fed R.Civ.P. 33(a), 28 U.S.C. 1651, 3201 et seq. The principal purpose for gathering this information is to evaluate your ability to pay the Government claim or judgment against you. Routine uses of the information are established in the following U.S. Department of Justice Case File Systems published in Vol. 42 of the Federal Register: Justice/CIV-001 at page 53321; Justice/TAX-001 at page 15347; Justice/USA-00 at pages 53408-53410, Justice/CRIM-016 at page 12774. If the requested information is not furnished, the U.S. Department of Justice has the right to such disclosure of the information by legal methods.

Section 1
P e rso na l I n f o r m a t io n

1 . Full Name(s) _______________________________ _______________________________ S tr e e t Address: _______________________________ C i ty ____________________ State ______ Zip _______ C o u n ty of Residence: __________ How long at this address? _____________ 3 . Your Social Security Number ___________________ 4 . Your Date of Birth __________________

1 a . Home Telephone: ( ) ___________________ 1 b . Cellular Number: ( )___________________ 2 . Marital Status: ~ Married ~ Separated ~ Not Married (single, divorced, widowed) 2 a . Spouse's Name ___________________________ 2 b . Spouse's Date of Birth________________

5 . ~ Own Home ~ Rent ~ Other (specify, i.e. share rent, live with relative) _____________________________ ___________________________________________________________________________________________ 6 . List the dependants you can claim on your tax return F i r s t Name Relationship Age Does this person live with you? ____________________ _____________ ______ ~ Yes ~ No ____________________ _____________ ______ ~ Yes ~ No ____________________ _____________ ______ ~ Yes ~ No

Section 2
E m p lo ym e nt I n f o r m a ti o n

7 . Your employer ______________________________ S tr e e t Address _________________________________ C i ty ____________________ State ______ Zip _______ W o r k telephone No. ( ) _____________________ 7 a . How long with this employer? __________________ 7 b . Occupation (title)____________________________

8. Spouse's employer ____________________________ Street Address __________________________________ City ____________________ State ______ Zip _______ W o r k telephone No. ( ) _______________________ 8a. How long with this employer? __________________ 8b. Occupation (title) ____________________________

Ú Ú Ú Ú Ú ATTACHM E N T S REQUIRED: Please provide proof of gross earnings and deductions for the past 3 m o n t h s from each employer (i.e. pay stubs, earning statements).

Section 3
Y our B u s in e ss I n f o r m a ti o n

9 . Are you or your spouse self-employed or operate a business? (Check "Yes" if either applies) ~ Yes ~ No I f yes, provide the following information: 9 a . Name of Business ______________________________ 9 c . Employer Identification No._________________ 9 b . Street Address _________________________________ C i ty _______________________ State ____________ Zip _____________ Telephone ( )_______________ Ú Ú Ú Ú Ú ATTACHM E N T S REQUIRED: Please provide proof of self-employment income for the prior 3 months (i.e. invoices, commissions, tax returns, sales records, income statement)

Name_____________________________
Section 4
O th e r Inco m e I n f o r m a ti o n

SSN_____________________

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2

1 0 . Do you receive income from sources other than your employer and/or own business (Check all that apply) ~ Pension ~ Social Security ~ Other (specify, i.e. child support, alimony, rental property) ________________________________________________________

Ú Ú Ú Ú Ú ATTACHM E N T S REQUIRED: Please provide proof of pension/social security/other income for the p a s t 3 months from each payor, including any statements showing deductions.

Section 5
B a n k in g , I n v e stm e n t, C a s h , Credit a n d Life Ins. I n f o r m a ti o n

1 1 . CHECKING ACCOUNTS. List all checking accounts T yp e of A c c o u nt C h e c kin g F u l l name of Bank, Credit C u r r e n t Account U n io n or Institution B a n k Account No. B a la n c e N a m e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________ $_____________ A d d r e ss _______________________ C i ty _____________________ S ta te _________ Zip__________

11a.

11b.

N a m e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________ $_____________ A d d r e ss _______________________ C i ty _____________________ S ta te _________ Zip__________ ____________________________________________________________________________________________ 1 2 . OTHER ACCOUNTS. List all other accounts including savings, brokerage and money market, not listed in 11. T yp e of A c c o u nt ___________ F u l l name of Bank, Credit C u r r e n t Account U n io n or Institution B a n k Account No. B a la n c e N a m e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________ $_____________ A d d r e ss _______________________ C i ty _____________________ S ta te _________ Zip__________ Name_________________________ ________________ $_____________ A d d r e ss _______________________ C i ty _____________________ S ta te _________ Zip__________

C h e c kin g

12a.

12b.

___________

Ú Ú Ú Ú Ú ATTACHM E N T S REQUIRED. Please include your current bank/financial statements for the past 3 m o n t h s for all accounts. ____________________________________________________________________________________________ 1 3 . INVESTM E N T S . List all investment assets below. Include stocks, bonds, mutual funds, stock options, c e r t ific a te s of deposits and retirement assets such as IRAs, Keogh and 401(k) plans. N a m e of Company Number of Shares C u r r e n t Value 1 3 a . ___________________________ ______________ $_____________ 1 3 b . ___________________________ ______________ $_____________ 1 3 c . ___________________________ ______________ $_____________ ____________________________________________________________________________________________ 1 4 . CASH ON HAND. Include any money that you have that is not in the bank. 1 4 a . Total Cash on Hand $_________________ ____________________________________________________________________________________________ 1 5 . CREDIT DEBT. List all lines of credit, including credit cards and signature loans. (Attach a separate sheet if you need more space.) 1 5 a . Full name of Credit Institution C r e d i t Limit C u r r e n t Balance N a m e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $___________ $____________ A d d r e ss _______________________ C i ty _____________________ S ta te _________ Zip__________ Minimum Monthly Payment $________________

Name_____________________________
Section 5
( c o ntin u e d )

SSN_____________________

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3

1 5 b . Full name of Credit Institution C r e d i t Limit C u r r e n t Balance N a m e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $___________ $____________ A d d r e ss _______________________ C i ty _____________________ S ta te _________ Zip__________

Minimum Monthly Payment $________________

1 5 c . Full name of Credit Institution C r e d i t Limit C u r r e n t Balance Minimum Monthly Payment N a m e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $___________ $____________ $________________ A d d r e ss _______________________ C i ty _____________________ S ta te _________ Zip__________ ____________________________________________________________________________________________ 1 6 . LIFE INSURANCE. Do you have life insurance with a cash value? ~ Yes ~ No (Term Life Insurance does not have a cash value) 16a. Name of Insurance Company ________________________________________________ 1 6 b . Policy Number(s) _________________________________________________________ 1 6 c . Owner of Policy __________________________________________________________ 1 6 d . Current Cash Value $_____________________ 1 6 e . Outstanding Loan Balance (if applicable) $__________________________

Section 6
O the r

1 7 . OTHER INFORM A T I O N . Respond to the following questions related to your financial condition: ( A t t a c h a separate sheet if you need more space.) 1 7 a . Do you have a safe deposit box? ~ Yes ~ No If yes, please include the name and address of location of box, the box number and the contents below: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 1 7 b . Do you have a will? ~ Yes ~ No; if yes, where is it kept? _______________________________________ 1 7 c . Are there any garnishments against your wages ~ Yes ~ No If yes, who is the creditor?________________ _________________________________ Date of Judgment ______________ Amount of Debt $_____________ 17d. Are there any judgments against you? ~ Yes ~ No If yes, who is the creditor/plaintiff?________________ _________________________________ Date of Judgment ______________ Amount of Debt $_____________ 17e. Are you a party to a lawsuit? ~ Yes ~ No If yes, amount of suit $_______________ Possible completion date ________________ Court ___________________________________________________ S u b j e c t of suit ________________________________________________________________________________ 1 7 f. Have you ever filed bankruptcy? ~ Yes ~ No If yes, date filed _______________________ D a te discharged _________________________ 1 7 g . In the past 10 years have you transferred any assets out of your name for less than their actual value? ~ Yes ~ No If yes, what asset(s)? __________________________ Value of asset at time of transfer $_________ W h e n was it transferred? ________________ To whom was it transferred? ________________________________ 1 7 h . Do you anticipate any increase in household income in the next 2 years? ~ Yes ~ No I f yes, why will the income increase? _________________________________ How much will it increase? _______ 1 7 i. Are you a beneficiary of a trust or an estate? ~ Yes ~ No If yes, name of trust/estate?________________ I f yes, anticipated amount to be received? $_______________ W h e n will amount be received? _________________ 1 7 j . Are you a participant in a profit sharing plan? ~ Yes ~ No If yes, name of plan?_______________________________________________ Value of plan $ ________________

Name_____________________________
Section 7
A s s e t s and L ia b ilitie s

SSN_____________________

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4

1 8 . PURCHASED AUTOM O B I L E S , TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV's, m o t o r c y c l e s , trailers, etc. (if you need additional space, attach a separate sheet.) Description *Current Current Loan (year, make, model) Value Balance 18a. _______________________ $ _ _ _ _ _ _ _ $__________ ___________________________ Name of Purchase Lender Date ____________________ __________ ____________________ Monthly Payments $________

* Current V a lu e is th e amount y o u could s e ll the asset fo r today

1 8 b . _______________________ $ _ _ _ _ _ _ _ $__________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________________ ____________________

$________

1 9 . LEASED AUTOM O B I L E S , TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV's, m o t o r c y c l e s , trailers, etc. (if you need additional space, attach a separate sheet.) Description Current Lease Name of Lease Monthly (year, make, model) Balance Lender Date Payments 1 9 a . _________________________ $__________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $________ _____________________________ ____________________ 1 9 b . _________________________ _____________________________ $__________ ____________________ __________ ____________________ $________

Ú Ú Ú Ú Ú ATTACHM E N T S REQUIRED. Please include your current statement from lender with monthly v e h i c l e payment and current balance of the loan for each vehicle purchased or leased. ____________________________________________________________________________________________ 2 0 . REAL ESTATE. List all real estate you own. (If you need additional space, attach a separate sheet.) L e n d e r / L i e n Holder Street Address, City S t a te , Zip 2 0 a ._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________ ___________________ A c t u a l Property S t r e e t Address, City S t a te , Zip __________________ __________________ __________________

D a te P urchased ____________

P u rc h a se P r ic e

C u rr e n t B a la n c e

Monthly Payment

$ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ $_________

2 0 b ._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ $_________ ___________________ __________________ ___________________ __________________ ____________________________________________________________________________________________ 2 1 . PERSONAL ASSETS. List all personal assets below. (If you need additional space, attach a separate sheet.) Line 21a. Furniture/Personal effects includes the total current market value of your household such as furniture and appliances. Line 21b. Other includes all jewelry, artwork, antiques, collections and/or other assets not already listed on this statement. Current Loan Monthly Description Value Balance Lender Payment 2 1 a . Furniture/Personal Effects $___________ $____________ ____________________ $__________ ( s e e note above) 2 1 b . Other (see note above) __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________

$___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________

$____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________

____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

$__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

Name_____________________________
Section 8
M o n th ly I n c o m e and E x p e n se S o u rc e M o n thly

SSN_____________________
TOTAL LIVING EXPENSES

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5

TOTAL INCOME

E x p e n s e Items (W e generally do not allow you to claim tuition fo r private schools, college expenses, charitable donations, or v o l u n t a r y retirement contributions.)

NOTE:
E v e n if only o n e spouse has a debt, but both have in c o m e , lis t the total h o u s e ho ld in c o m e and e x p e n s e s.

22a. Gross Wages (you) $__________
2 2 b . Gross W a g e s (spouse)$__________ 2 2 c . Interest/Dividends $__________ 22d. Net Business Income $__________ 2 2 e . Net Rental Income $__________ 2 2 f. Pension/Social Security (you) $__________ 22g. Pension/Social Security (spouse) $__________ 2 2 h . Child Support $__________

Items
2 3 a . Rent/Mortgage 2 3 b . Electric 2 3 c . Natural Gas 2 3 d . Cable TV 23e. Telephone 2 3 f. W a te r 2 3 g . Food 2 3 h . Car Payment 2 3 i. Gasoline 2 3 j . Car Insurance 2 3 k . Cell Phone/Pager 2 3 l. Clothing & Misc. 2 3 m . Court Ordered Payments 2 3 n . Child Support 2 3 o . Child/Dependant Care 2 3 p . Life Insurance 2 3 q . Other expenses (specify)

22i. Alimony 22j. Other

$__________ $__________

D E D U C T I O N S FROM W A G E S ( in c l u d in g spouses) M o n th ly 2 4 a . Taxes (Federal, $__________ S t a te , FICA, etc.) 2 4 b . Insurance $__________ 2 4 c . Union Dues $__________ 2 4 d . Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $__________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $__________

Actual Monthly $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

_____________________
_______________________

_____________________
_______________________

Ú Ú Ú Ú Ú ATTACHM E N T S REQUIRED. Please include: C A copy of your last Form 1040 with all schedules C P r o o f of all current expenses that you paid for last 3 months, including utilities, rent, insurance, property ta x e s , etc. C C o p ie s of any court order requiring payment and proof of such payments for the last 3 months. C C o p i e s of any paperwork to support claims on lines 22j, 23q or 24d. PAYM ENTS PROPOSED M O N T H L Y PAYM E N T IS: $_____________ ON ________ DAY OF THE M O N T H .

C E R T IF IC A T IO N I declare that I have examined the information given in this statement and, to the best of my knowledge and belief, it is true, correct a n d complete, and I further declare that I have no assets, owned either directly or indirectly or income of any nature other than as s h o w n in this statement, including any attachment. ________________________________________________________________________________________________________ S ign a tur e Social Security No. Date

W A R N IN G F a l s e statements are punishable up to five years imprisonment, a fine of $250,000 or both pursuant to 18 U.S.C. §1001.

ATTACHMENT A 1. 2. Earning statements from your most recent paychecks. Business records for the present year and past calendar year which reflect assets, liabilities, gross receipts and expenses for any sole proprietorship, partnership or corporation in which you, or your spouse, own any interest. Current bank statements for the past 12 months from all banks or other financial institutions, where any sole proprietorship, partnership, or corporation in which you, or your spouse, own any interest, has an account of any kind. Current bank statements for the past 12 months from all banks, or other institutions, where you, or your spouse, have an account of any kind. All trust agreements in which you, or your spouse, are named trustor, trustee or beneficiary. All deeds, leases, contracts, and other documents representing any ownership interest you, or your spouse, have in any real property, and all deeds of thrust, mortgages, or other documents evidencing encumbrances of any kind on your real property. All stocks, bonds, or other securities of any class you may own, by you separately or jointly with others, including options to purchase any securities. Titles to all motor vehicles owned by you or your spouse. All life insurance policies in which you are either the insured or the beneficiary. All promissory notes held by you, and all other documents evidencing any money owed to you either now or in the future. All financial statements furnished by you within the past five years. All deeds, bills of sale, or other documents prepared in connection with any transfer made by you, either by gift, sale, or otherwise within the last five years. A schedule of all regular expenses paid by you, such as installment debts, food, utilities, etc. Include the amount paid, the payee, and, if an installment debt, the amount of debt owing and any security pledged. All documents evidencing any interest you have in any pension plan, retirement fund, or profit-sharing plan. All records pertaining to your assets and finances.

3.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13.

14. 15.

16. 17.

Copies of income tax returns for the past three years. All records of any unincorporated business of which you are an owner or partowner, or have been an owner within the past three years.