USA v. Lawler

Filing 10

ORDER to Discover and to Appear for Hearing on Periodic Payment of the Judgment, (Hearing set for 11/24/2009 09:15 AM before Magistrate Judge James R. Muirhead.) Signed by Magistrate Judge James R. Muirhead. (Attachments: # 1 Exhibit A - Financial Statement, # 2 Exhibit B - Request for Documents)(mm)

FINANCIAL DISCLOSURE STATEMENT TO BE COMPLETED BY INDIVIDUAL DEFENDANT A. GENERAL INSTRUCTIONS - READ CAREFULLY

The information requested in the following form is to be submitted concerning a current case in connection with an asset investigation. Prior to completing and submitting this form, you should discuss this matter and this form thoroughly with your own attorney. The purpose of this form is to determine what assets you may have or are in control of. If you are married or have a live-in companion, you must list assets held by your spouse or companion, as well as yourself, and show whether each asset is owned individually or jointly. By completing and signing this financial disclosure statement, you acknowledge that the information provided will affect action by the United States Department of Justice and further understand that any false answers can lead to prosecution for false statements as provided under Title 18, United States Code, Section 1001 (maximum prison sentence of five (5) years and/or a fine of not more than $250,000). Each separate question must be answered completely. If the answer is "none" you must state "none." Do not leave any question unanswered. You must date and initial each page, and sign the last page. If there is insufficient space on the form, please attach additional sheets as necessary, and date and initial each additional page. B. ACKNOWLEDGMENT, IF REPRESENTED BY COUNSEL

I _____ am ______ am not (check one) represented by counsel in the collection of this debt. If I am represented by retained or appointed counsel, I acknowledge having reviewed the foregoing instructions with my counsel. My counsel's name is _______________________________. Date: __________ Name: ___________________________________________________ Last First Middle

Signature ___________________________________________ ______________________________________________________________________________
Authority for the solicitation of the requested information includes one or more of the following: 5 U.S.C. § 301, 901 (see Note, Executive Order 6166, June 10, 1933); 28 U.S.C. § 501-530A; 28 U.S.C. § 1651, 3201-3206, 31 U.S.C. § 3701-3731; 44 U.S.C. § 3101; 4 C.F.R. § 101-101.8; 28 C.F.R. § 0.160, 0.171 and Appendix to Subpart Y; 18 U.S.C. § 3664(d)(3). The principal purpose for gathering this information is to evaluate your ability to pay the government's 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 5332; Justice/TAX001 at page 15347; Justice/USA-005 at pages 53406-53407; Justice/USA-007 at pages 53408-53410; Justice/CRIM016 at pages 12774. Disclosure of the information is voluntary. If the requested information is not furnished, the United States may seek disclosure through other names.

UNITED STATES DEPARTMENT OF JUSTICE UNITED STATES ATTORNEY FINANCIAL STATEMENT OF INDIVIDUAL DEBTOR
PERSONAL IDENTIFICATION ____________________________________________________________________________________________ 1. Name (Debtor) 2. Birth Date (Mo. Day Yr.) 3. Taxpayer Identification No. (SSN or EIN) ____________________________________________________________________________________________ 4. Home Address (Street) 5. Driver's License No./State ____________________________________________________________________________________________ (City, State & Zip Code) 6. Home Phone () ____________________________________________________________________________________________ EMPLOYER OR BUSINESS ____________________________________________________________________________________________ 7. Present Employer or Business Name 8. Employer or Business Tel. No. () ____________________________________________________________________________________________ 9. Employer or Business Address (Street) 10. Job Title/Occupation ____________________________________________________________________________________________ (City, State & Zip Code) 11. Years in Present Job or Business ____________________________________________________________________________________________ 12. List other employers or businesses you have had in the last 3 years. Employer or Business Name Phone No. Employment () Da t e ____________________________________________________________________________________________ Employer or Business Name Employer or Business Address Phone No. Employment () Da t e ____________________________________________________________________________________________ SPOUSE/COMPANION ____________________________________________________________________________________________ 13. Provide current spouse's/companion's name 14. Social Security No. 15. Birth Date (Mo. Day Yr.) ____________________________________________________________________________________________ 16. If spouse's home address is different, list below. ____________________________________________________________________________________________ 17. List spouse's/companion's present employer's name and address. 18. Employer's Phone No. () ____________________________________________________________________________________________ 19. Job Title 20. Years in Present Job ____________________________________________________________________________________________ Initials ________ Employer or Business Address

12/06

21. Spouse's/Companion's annual gross salary/wages is $_______________

Spouse's/Companion's take-home pay is $ _____________ per ___________

22. Does spouse/companion receive alimony or child support from a previous marriage? If yes, amount $________________ ____________________________________________________________________________________________ DEPENDENTS ____________________________________________________________________________________________ 23. List all dependents who live with you: ____________________________________________________________________________________________ Name Age Relationship ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 24. List names and addresses of all dependents not living with you: _______________________________________________________________________________________ Name/Address Age Relationship ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 25. List amount of monthly income received by dependents from any sources other than you or your spouse. 26. Total monthly amount paid by you or your spouse to dependents listed in item 23 (example: child support, alimony, etc.). 27. List names and addresses of Parents/In-laws if living: ____________________________________________________________________________________________ SALARY, WAGES OR COMMISSIONS (space provided for you as well as your spouse/companion) ____________________________________________________________________________________________ INCOME: (Estimate of average monthly income) D EBTOR SPOUSE/COMPANION 28. Current monthly gross wages, salary and commissions (Prorate if not paid monthly.) 29. Estimate monthly overtime 30. SUBTOTAL $ _______________ $ ________________ $ _______________ $ ________________ $_____________ $_____________

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31. LESS PAYROLL DEDUCTIONS a. b. c. d. e. f. g. h. Federal Taxes State/County/City Taxes Social Security Taxes (FICA/Medicare) Medical Insurance Union Dues if applicable Allotments to Credit Union, Bank or others Life Insurance List any other payroll deductions (Including 401(k) contributions) I. Other (specify) 32. SUBTOTAL OF PAYROLL DEDUCTIONS 33. TOTAL NET MONTHLY TAKE-HOME PAY 34. Regular income from operation of business or profession or farm (attach detailed statement) 35. Income from real property 36. Interest and dividends 37. Alimony, maintenance or support payments payable to the debtor for the debtor's use or that of dependents listed above 38. Social security or government assistance (specify): _____________________________ 39. Pension or retirement income 40. Other monthly income (specify): _____________________________ 41. SUBTOTAL OF LINES 34 through 40 42. TOTAL MONTHLY INCOME (add amounts shown on lines 33 and 41) 43. TOTAL COMBINED MONTHLY INCOME: $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________

$ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________

$ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________

$ _____________________

44. Describe any increase or decrease in income reasonably anticipated to occur within the year following the filing of this document: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

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45. Did you file a Federal Income Tax Return last year? Yes ____ No ____ Joint ____ Individual ____ Amount of Gross Income on return was: $___________________

46. Did you apply for a tax refund on your most recently filed Federal, State, City or County tax return? Yes ____ No ____ If YES, list the amount of the refund and from whom it will be received. Total Amount of Refund: $ _____________ Received from: _____________________________________

47. Do you owe delinquent taxes? Yes ____ No ____ If YES, list year and amounts due. _____________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

48.

Do you have any other earned income from any other source or business? Yes ____ No ____ a. If yes, please identify each source and state your monthly gross earnings (salary, wages, commissions, etc., from each source.

____________________________________________________________________________________________ b. Source c. Income ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

49.

CHILD SUPPORT PAYMENTS RECEIVED - Do you or your spouse/companion receive child support payments? If yes, complete the following: Yes ____ No ____

____________________________________________________________________________________________ Name of Dependent's Name of Non-Custodial Name of Custodial of Dependent Date of Birth Parent Parent List arrearage (if any) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

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____________________________________________________________________________________________ FIXED MONTHLY EXPENSES ____________________________________________________________________________________________

Complete this schedule by estimating the average monthly expenses of the debtor and the debtor's family. Pro rate any payments made by-weekly, quarterly, semi-annually, or annually to show monthly rate.
50. Rent or home mortgage payment (include lot rent for mobile home) a. Are real estate taxes included? Yes ____ No ____ $____________________

b. Is property insurance included? Yes ____ No ____ 51. Utilities: a) electricity and heating fuel b) water and sewer c) telephone d) other ____________________________________________ 52. Home maintenance (repairs and upkeep) 53. Food 54. Clothing 55. Laundry and dry cleaning 56. Medical and dental expenses 57. Transportation (not including car payments) 58. Recreation, clubs and entertainment, newspapers, magazines, etc. 59. Charitable contributions 60. Insurance (not deducted from wages or included in home mortgage payments) a. Homeowner's or renter's b. Life c. Health d. Auto e. Other ______________________________________________ 61. Taxes (not deducted from wages or included in home mortgage payments) (Specify) _____________________________________________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________

Initials ________ 62. Installment payments:

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a. Auto b. Other c. Other 63. Alimony, maintenance, and support paid to others 64. Payments for support of additional dependents not living at your home 65. Regular expenses from operation of business, profession, or farm (attach detailed statement) 66. Other

$____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________

67. TOTAL MONTHLY EXPENSES ____________________________________________________________________________________________

68.
Creditor

List credit card or other debts you owe, including any installment payments (attach additional pages as needed)

Date of Debt Total Amount Date of Last Payment Amt. Frequency of and Purpose Due Payment Payments ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

69. Total credit card or other payments paid per month

$ ___________________

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REAL PROPERTY ____________________________________________________________________________________________

70.

Do you or your spouse/companion have any interest in any real estate anywhere in the world? Yes ___ No ___ (This includes any real estate currently being sold under contract.) If YES, identify each real estate interest as stated below.

a. Complete Address b. Name c. Purchase d. Fair Market e. Balance due f. Monthly g. Date Mtg. h. To Whom (include State & County) on Deed Price Value on Mortgage Payment Paid Off Payments Owed ____________________________________________________________________________________________________________________ $ $ $ $ ____________________________________________________________________________________________________________________ $ $ $ $ ____________________________________________________________________________________________________________________ $ $ $ $ ____________________________________________________________________________________________________________________ $ $ $ $ ____________________________________________________________________________________________________________________

71.

Do you rent any of the property listed above to others? Yes ____ No ____ If YES, amount of rent?

Property ___________________________________________________________ $ _______________________ Name of Renter: _____________________________________________________ Property ___________________________________________________________ $ _______________________ Name of Renter: _____________________________________________________

72.

RENTAL AGREEMENT. Do you or your spouse/companion rent the premises on which you live? Yes ____ No ____ If YES, please complete the following:

a. Name of b. Address/Telephone c. Payment Schedule. d. Rent e. Utilities f. Deposit or Landlord No. Of Landlord (weekly, monthly, annually) Payment Included in rent funds held by landlord __________________________________________________________________________________________________________________ ______________________ ______________________ ______________________ __________________________________________________________________________________________________________________ $ $

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73.

Do you receive or expect to receive aid to families with dependent children, unemployment compensation or any other type of assistance from the United States, your own state, any other governmental agency or any other person? Yes ____ No ____ If YES, List the source and amount.

_____________________________________________________________________________________________________________ a. Source of Payment b. Program c. Payment Amount d. Payment Schedule (name of person, state, etc.) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

74.

Name of each bank, credit union and any other financial institute or company with which you, your spouse/companion, or any other person or entity associated with you, have or have ever had any account at any time during the past five (5) years.

a. Name of Financial b. Name (s) on Account c. Account No. & Type d. Current Balance in Account Institution and address or date closed _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

75.

SAVINGS BONDS: Do you, your spouse/companion or your depndants own U.S. Savings Bonds?

a. Denomination of Bond b. Name (s) on Bond c. Purchase Date d. Value ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

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76.

INDIVIDUAL RETIREMENT ACCOUNT. Do you or your spouse have any Individual Retirement Account ("IRA"), Keogh Account, other retirement account or savings, or any interest in any profit-sharing or pension plan? Yes ____ No ____ If YES, please identify each account by name of financial institution, address, account number and name on account.

a. Name of Financial b. Name (s) on Account c. Account No. & Type d. Current Balance in Account Institution and address or date closed _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

77.

SAFETY DEPOSIT BOXES: Do you or your spouse, or any other person maintain or rent a safety deposit box in your name(s) or in any other name? Yes ____ No ____ If YES, give name and address of bank(s) and name(s) utilized to open or maintain the safety deposit box(es).

a. Name of Financial b. Is it currently c. Safety Deposit d. Contents e. If closed, date closed Institution & Address maintained Box No. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

78.

Do you, your spouse or dependents have any cash over $5,000? If so, identify the amount and location: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 79. Have you, your spouse or dependents have any money market, brokerage or other accounts in the past six years? If so, identify the financial institution and current or closing balance of each account.
ACCOUNT NUMBER ACCOUNT HOLDER CURRENT BALANCE OR DATE CLOSED

BANK

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
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80.

Have you, your spouse or dependents had any foreign bank accounts in the past six years? If so, identify the financial institution where located, and current or closing balance of each account.
ACCOUNT NUMBER ACCOUNT HOLDER CURRENT BALANCE OR DATE CLOSED

BANK

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 81. Have you, your spouse or dependants had any certificates of deposit or treasury notes within the past six years? If so, identify the amount and where maintained. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 82. Do you, your spouse or dependents have any travelers checks? If so, identify the amount and where maintained. __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 83. Have you, your spouse or dependents had any securities (bonds, stocks, notes, mortgages or real estate investment trusts) within the past six years? If so, identify the amount and where maintained. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 84. Have you, your spouse or dependents had any tax exempt funds, municipal bonds within the past six years? If so, identify the amount and where maintained. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 85. Have you, your spouse or dependents had any equity securities or commodity contracts within the past six years? If so, identify the nature and value and where maintained. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 86. Have you, your spouse or dependents had any mutual funds within the past six years? If so, identify the value and where maintained. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
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87.

Have you, your spouse or dependents had any brokerage accounts or brokers' margin accounts within the past six years? If so, identify the institution.

CURRENT BALANCE BANK ACCOUNT NUMBER ACCOUNT HOLDER OR DATE CLOSED _________________________________________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 88. Do you, your spouse or dependents have any accounts receivable (including principal amount, maturity date, market value)? If so, identify the amounts that are owed and from whom. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 89. Do you, your spouse or dependents have any annuity contracts? If so, give complete details. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 90. Are you, your spouse or dependents entitled to receive any alimony or child support payments? If so, give complete details. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 91. Have you, your spouse or dependents held any promissory notes or made any loans to any person or entity that are still outstanding? If so, give complete details. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 92. Have you, your spouse or dependents had any business interests (including sole proprietorships, partnerships, corporations) within the past six years? If so, give complete details. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 93. Do you, your spouse or dependents lease any vehicles? If so, identify make, model, date of purchase, or loan agreement, and current value. __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
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94.

Do you drive a motor vehicle owned or leased by someone else? Identify the make, model, year and owner and/or lessee of vehicle. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 95. Do you or your spouse have any life insurance policies? Yes ___ No ____ If YES, state:

(a) Company name, address, phone number: ___________________________________________________________________________ ___________________________________________________________________________ (b) Type of insurance (term, whole life, etc.): ___________________________________________________________________________ ___________________________________________________________________________ (c) Policy Number: ___________________________________________________________________________ ___________________________________________________________________________ (d) Face Value Amount: ___________________________________________________________________________ ___________________________________________________________________________ (e) Cash Surrender Value: ___________________________________________________________________________ ___________________________________________________________________________ (f) Outstanding Loans On Policy: ___________________________________________________________________________ ___________________________________________________________________________ 96. List all other personal property owned or being purchased by you, your spouse or dependants. (Attach additional sheets if needed)

_________________________________________________________________________________________________________________ Identify specific Asset, Owner, Registration No. Date Current Asset (attach additional sheets if needed) and Location Purchased Value _________________________________________________________________________________________________________________ Motor vehicle(s)(cars, trucks, SUV's etc.) _________________________________________________________________________________________________________________ Camper/recreational vehicle(s) _________________________________________________________________________________________________________________ Motorcycle/motorbike(s) _________________________________________________________________________________________________________________ Boats(s) _________________________________________________________________________________________________________________ Initials ________

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________________________________________________________________________________________________________________ Identify specific Asset, Owner, Registration No. Date Current Asset Purchased Value (attach additional sheets if needed) and Location _________________________________________________________________________________________________________________ Jewelry with total value over $1,000 _________________________________________________________________________________________________________________ Antiques, art objects or stamp collections _________________________________________________________________________________________________________________ Other personal property with value over $1,000 _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

97. 98.

State highest level of education received. ______________________________________

Do you anticipate any job changes during the next year? Yes ____ No ____ If YES, give specific details. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 99. Are there any reasons to believe your salary/wages will substantially change during the next year? Yes ____ No ____ If YES, give specific details. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 100. Are you involved in any lawsuits in which you might receive money or something of value? Yes ____ No ____ If YES, give specific details. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 101. Are you involved in any lawsuits in which you might be required to pay money or transfer something of value? Yes ____ No ____ If YES, give specific details ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 102. Are there outstanding unpaid judgments against you for any debts other than this one? Yes ____ No ____ If YES, give specific details. ______________________________________________________________________________ ______________________________________________________________________________
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103.

Are you a Trustee, Executor or Administrator of an estate? Yes ____ No ____ If YES, give specific details. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 104. Is anyone holding money or any other assets on your behalf? Yes ____ No ____ If YES, give specific details. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 105. Is there any likelihood you, your spouse or dependent will receive any inheritance? Yes ____ No ____.

IF YES, FROM WHOM? (name, address and phone number) ______________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 106. Have you renounced any inheritance rights within the last three years? If so, provide the details of whose estate, and provide all documents executed by you in connection with this. ___________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________ 107. List all transfers of property including cash (by loans, gift, sale, etc.) that you have made within the last six (6) years. (Items of $1,000 or more in value). Use additional sheets if necessary:

DATE AMOUNT PROPERTY TRANSFERRED TO WHOM ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 108. Are your wages and/or those of your spouse being garnished at this time? Yes ____ No ____ If YES, give specific details ____________________________________________________________________________ ____________________________________________________________________________ ______________________________________________________________________________
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109.

Do you owe any medical bills in excess of $1,000? Yes ____ No ____ If YES, give specific details: ____________________________________________________________________________ ____________________________________________________________________________ ______________________________________________________________________________ 110. Do you receive or, under any circumstances, expect to receive benefits from any established trust, from a claim for compensation or damages, or from a contingent or future interest in property of any kind? Yes ____ No ____. If YES, give details: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 111. Do you have any outstanding loans payable to banks, finance companies, etc.? Yes ____ No _____ If YES, give details: Owed To Purpose Amount Payment Balance

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ 112. Are you self-employed or do you own all or part of a business as sole owner, partner, stockholder, or otherwise? Yes ____ No ____. If YES, state the name and address of the business: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ a. State the nature and value of your interest: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ b. How and when do you draw money from it? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

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c. Give an accurate account of the financial condition of this business for the last six years. Attach copies of the most recent three returns and a statement of assets, inventories, liabilities, gross and net income, and the amount of any undistributed profits in the business: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

With knowledge of the penalties for false statements provided by 18 United States Code § 1001 (a fine of up to $250,000 and/or five years imprisonment) and with knowledge that this financial statement is submitted by me to affect action by the United States Department of Justice, I certify that I believe the above statement is true and that it is a complete statement of all of my income and assets, real and personal, whether held in my name or by any other. ____________________________ Date __________________________________________ Signature __________________________________________ (Print Name)

____________________________________________________________________________________________ * If you attached additional sheets to this form, you must also sign those sheets. * Attach a copy of your most recent pay slip to this form. * Attach copies of the last 3 Federal Income Tax Returns you have filed. ____________________________________________________________________________________________

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