Federal Trade Commission v. The Cuban Exchange, Inc. et al

Filing 14

ORDER granting 2 Motion for TRO: SEE ATTACHED TEMPORARY RESTRAINING ORDER. It is further Ordered that pursuant to Fed. R. Civ. P. 65(b), Defendants shall appear before Magistrate Judge Levy on the 12th day of December, 201 2, at 10:30 a.m. in Courtroom 1223 South at the United States Courthouse located at 225 Cadman Plaza East, Brooklyn, NY 11201 to show cause, if there is any, why a Report and Recommendation should not issue recommending the entry of a prelimin ary injunction against Defendants enjoining them from further violations of the FTC Act and the TSR as alleged in the Complaint and imposing such additional relief as may be appropriate pending final adjudication of the Complaint filed in this matter. Ordered by Judge Roslynn R. Mauskopf on 11/30/2012. (Attachments: # 1 Attachments A&B (Financial Statements)) (Mauskopf, Roslynn)

Case 1:12-cv-05890-NGG-RML Document 9-1 Filed 11/29/12 Page 1 of 12 PageID #: 200

ATTACHMENT A

Case 1:12-cv-05890-NGG-RML Document 9-1 Filed 11/29/12 Page 2 of 12 PageID #: 201
FEDERAL TRADE COMMISSION
FINANCIAL STATEMENT OF INDIVIDUAL DEFENDANT
Definitions and Instructions:
1. Complete all items. Enter “None” or “N/A” (“Not Applicable”) in the first field only of any item that does not apply
to you. If you cannot fully answer a question, explain why.
2. “Dependents” include your spouse, 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.
3. “Assets” and “Liabilities” include ALL assets and liabilities, located within the United States or any foreign country
or territory, whether held individually or jointly and whether held by you, your spouse, or your dependents, or held
by others for the benefit of you, your spouse, or your dependents.
4. 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.
5. Type or print legibly.
6. Initial each page in the space provided in the lower right corner.
7. 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 the executive, legislative, or judicial branch of the Government of the
United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or devise a material fact;
makes any materially false, fictitious or fraudulent statement or representation; or makes or uses any false writing or
document knowing the same to contain any materially 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.

Federal Trade Commission Financial Statement of Individual Defendant

Case 1:12-cv-05890-NGG-RML Document 9-1 Filed 11/29/12 Page 3 of 12 PageID #: 202
BACKGROUND INFORMATION
Item 1. Information About You
Full Name

Social Security No.

Current Address of Primary Residence

Driver’s License No.

State Issued

Phone Numbers
)
Home: (
Fax: (
)
Rent

Own

From (Date):

Date of Birth:

/
/
(mm/dd/yyyy)
Place of Birth

E-Mail Address

/
/
(mm/dd/yyyy)

Internet Home Page

Previous Addresses for past five years (if required, use additional pages at end of form)
Address

From:

/
/
(mm/dd/yyyy)

Rent
Address

From:

From:

Rent

/
/
(mm/dd/yyyy)

Own

/

Rent
Address

Until:

/

Until:

/

/

Until:

/

/

Own

/

/

Own

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.

Address (if different from yours)

Phone Number

(

Date of Birth
/
/
(mm/dd/yyyy)
Place of Birth

)
Rent

/
/
(mm/dd/yyyy)
Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they were used:

Employer’s Name and Address

Own

From (Date):

Job Title
Years in Present Job

Annual Gross Salary/Wages
$

Item 3. Information About Your Previous Spouse
Name and Address

Social Security No.
Date of Birth
/
/
(mm/dd/yyyy)

Item 4. Contact Information (name and address of closest living relative other than your spouse)
Name and Address

Phone Number

(

)

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 5. Information About Dependents

(whether or not they reside with you)

Name and Address

Social Security No.

Date of Birth
/
/
(mm/dd/yyyy)

Relationship
Name and Address

Social Security No.

Date of Birth
/
/
(mm/dd/yyyy)

Relationship
Name and Address

Date of Birth
/
/
(mm/dd/yyyy)

Social Security No.
Relationship

Name and Address

Date of Birth
/
/
(mm/dd/yyyy)

Social Security No.
Relationship

Item 6. Employment Information/Employment Income
Provide the following information for this year-to-date and for each of the previous five full years, for each business entity of which you were a director,
officer, member, partner, employee (including self-employment), agent, owner, shareholder, contractor, participant or consultant at any time during that
period. “Income” includes, but is not limited to, any salary, commissions, distributions, draws, consulting fees, loans, loan payments, dividends,
royalties, and 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 and Address

Dates Employed

Income Received: This year to date
Year

From (Month/Year)
/
Ownership Interest?

From (Month/Year)
/

Yes

To (Month/Year)
/

Income

20

$
$

To (Month/Year)
/

No

Positions Held

$
$

/

/

$

/

/

$

Company Name and Address

Dates Employed

Income Received: This year to date
Year

From (Month/Year)
/
Ownership Interest?

From (Month/Year)
/

Yes

To (Month/Year)
/

Income

20

$
$

To (Month/Year)
/

No

Positions Held

$
$

/

/

$

/

/

$

Company Name and Address

Dates Employed

Income Received: This year to date
Year

From (Month/Year)
/
Ownership Interest?
Positions Held

Yes

To (Month/Year)
/

From (Month/Year)
/

To (Month/Year)
/

No

Income

20

$
$
$
$

/

/

$

/

/

$

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 7. Pending Lawsuits Filed By or Against You or Your Spouse
List all pending lawsuits that have been filed by or against you or your spouse in any court or before an administrative agency in the United States or in
any foreign country or territory. Note: At Item 12, list lawsuits that resulted in final judgments or settlements in your favor. At Item 21, list lawsuits that
resulted in final judgments or settlements against you.
Nature of
Status or
Caption of Proceeding
Court or Agency and Location
Case No.
Relief Requested
Proceeding
Disposition

Item 8. Safe Deposit Boxes
List all safe deposit boxes, located within the United States or in any foreign country or territory, whether held individually or jointly and whether 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.
Name of Owner(s)

Name & Address of Depository Institution

Box No.

Contents

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Federal Trade Commission Financial Statement of Individual Defendant

Case 1:12-cv-05890-NGG-RML Document 9-1 Filed 11/29/12 Page 6 of 12 PageID #: 205
FINANCIAL INFORMATION
REMINDER: When an item asks for information regarding your “assets” and “liabilities” include ALL assets and liabilities, located within
the United States or in any foreign country or territory, or institution, whether held individually or jointly, and whether 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. In addition, provide
all documents requested in Item 24 with your completed Financial Statement.

ASSETS
Item 9. Cash, Bank, and Money Market Accounts
List cash on hand (as opposed to cash in bank accounts or other financial accounts) and all bank accounts, money market accounts, or other financial
accounts, including but not limited to checking accounts, savings accounts, and certificates of deposit. The term “cash on hand” includes but is not
limited to cash in the form of currency, uncashed checks, and money orders.
a. Amount of Cash on Hand $
b. Name on Account

Form of Cash on Hand
Name & Address of Financial Institution

Account No.

Current Balance
$

$

$

$

$

Item 10. Publicly Traded Securities
List all publicly traded securities, including but not limited to, stocks, stock options, corporate bonds, mutual funds, U.S. government securities (including
but not limited to treasury bills and treasury notes), and state and municipal bonds. Also list any U.S. savings bonds.
Owner of Security

Issuer

Broker House, Address

Broker Account No.
Current Fair Market Value
$

Owner of Security

Issuer

Broker House, Address

Type of Security

No. of Units Owned

Loan(s) Against Security
$

Broker Account No.
Current Fair Market Value
$

Owner of Security

Issuer

Broker House, Address

Type of Security

No. of Units Owned

Loan(s) Against Security
$

Broker Account No.
Current Fair Market Value
$

Type of Security

No. of Units Owned

Loan(s) Against Security
$

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 11. Non-Public Business and Financial Interests
List all non-public business and financial interests, including but not limited to any interest in a non-public corporation, subchapter-S corporation, limited
liability corporation (“LLC”), general or limited partnership, joint venture, sole proprietorship, international business corporation or personal investment
corporation, and oil or mineral lease.
Entity’s Name & Address

Type of Business or Financial
Interest (e.g., LLC, partnership)

Owner
(e.g., self, spouse)

Ownership
%

If Officer, Director, Member
or Partner, Exact Title

Item 12. Amounts Owed to You, Your Spouse, or Your Dependents
Debtor’s Name & Address

Date Obligation
Incurred (Month/Year)
/
Current Amount Owed
$

Original Amount Owed
$

Nature of Obligation (if the result of a final court
judgment or settlement, provide court name
and docket number)

Payment Schedule
$

Debtor’s Telephone

Debtor’s Relationship to You

Debtor’s Name & Address

Date Obligation
Incurred (Month/Year)
/
Current Amount Owed
$

Debtor’s Telephone

Original Amount Owed
$

Nature of Obligation (if the result of a final court
judgment or settlement, provide court name
and docket number)

Payment Schedule
$

Debtor’s Relationship to You

Item 13. Life Insurance Policies
List all life insurance policies (including endowment policies) with any cash surrender value.
Insurance Company’s Name, Address, & Telephone No.

Policy No.

Insured

Loans Against Policy
$

Beneficiary

Policy No.

Insured

Insurance Company’s Name, Address, & Telephone No.

Beneficiary

Loans Against Policy
$

Face Value
$
Surrender Value
$
Face Value
$
Surrender Value
$

Item 14. 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,
other retirement accounts, and college savings plans (e.g., 529 Plans).
Trustee or Administrator’s Name, Address & Telephone No.

Name on Account
Date Established
/
/
(mm/dd/yyyy)

Trustee or Administrator’s Name, Address & Telephone No.

Account No.
Type of Plan

Surrender Value before
Taxes and Penalties
$
Account No.

Type of Plan

Surrender Value before
Taxes and Penalties
$

Name on Account
Date Established
/
/

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 15. Pending Insurance Payments or Inheritances
List any pending insurance payments or inheritances owed to you.
Type

Amount Expected

Date Expected (mm/dd/yyyy)

$

/

/

$

/

/

$

/

/

Item 16. Vehicles
List all cars, trucks, motorcycles, boats, airplanes, and other vehicles.
Vehicle Type

Registered Owner’s Name

Purchase Price
$

Make

Registration State & No.

Account/Loan No.

Model

Address of Vehicle’s Location

Lender’s Name and Address

Registered Owner’s Name

Purchase Price
$

Make

Registration State & No.

Account/Loan No.

Model

Address of Vehicle’s Location

Lender’s Name and Address

Registered Owner’s Name

Vehicle Type

Vehicle Type

Year

Year

Make

Registration State & No.

Purchase Price
$
Account/Loan No.

Model

Address of Vehicle’s Location

Registered Owner’s Name

Current Balance
$
Monthly Payment
$

Original Loan Amount
$
Current Value
$

Current Balance
$
Monthly Payment
$

Lender’s Name and Address

Vehicle Type

Year

Original Loan Amount
$
Current Value
$

Year

Make

Registration State & No.

Purchase Price
$
Account/Loan No.

Model

Address of Vehicle’s Location

Original Loan Amount
$
Current Value
$

Current Balance
$
Monthly Payment
$

Original Loan Amount
$
Current Value
$

Current Balance
$
Monthly Payment
$

Lender’s Name and Address

Item 17. Other Personal Property
List all other personal property not listed in Items 9-16 by category, whether held for personal use, investment or any other reason, including but not
limited to coins, stamps, artwork, gemstones, jewelry, bullion, other collectibles, copyrights, patents, and other intellectual property.
Property Category
(e.g., artwork, jewelry)

Name of Owner

Property Location

Acquisition Cost

Current Value

$

$

$

$

$

$

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Federal Trade Commission Financial Statement of Individual Defendant

Case 1:12-cv-05890-NGG-RML Document 9-1 Filed 11/29/12 Page 9 of 12 PageID #: 208
Item 18. Real Property
List all real property interests (including any land contract)
Type of Property

Property’s Location

Acquisition Date (mm/dd/yyyy)
/
/
Lender’s Name and Address

Purchase Price
$

Name(s) on Title or Contract and Ownership Percentages

Current Value
$
Loan or Account No.

Other Mortgage Loan(s) (describe)

Property’s Location

Purchase Price
$

Current Balance On First Mortgage or
Contract
$
Monthly Payment
$
Rental Unit

Monthly Payment
$
Monthly Rent Received
Current Balance
$
$
Name(s) on Title or Contract and Ownership Percentages

Type of Property

Acquisition Date (mm/dd/yyyy)
/
/
Lender’s Name and Address

Basis of Valuation

Current Value
$
Loan or Account No.

Other Mortgage Loan(s) (describe)

Basis of Valuation
Current Balance On First Mortgage or
Contract
$
Monthly Payment
$
Rental Unit

Monthly Payment
$
Current Balance
$

Monthly Rent Received
$

LIABILITIES
Item 19. Credit Cards
List each credit card account held by you, your spouse, or your dependents, and any other credit cards that you, your spouse, or your dependents use,
whether issued by a United States or foreign financial institution.
Name of Credit Card (e.g., Visa,
MasterCard, Department Store)

Account No.

Name(s) on Account

Current Balance
$
$
$
$
$

Item 20. Taxes Payable
List all taxes, such as income taxes or real estate taxes, owed by you, your spouse, or your dependents.
Type of Tax

Amount Owed

Year Incurred

$
$
$

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 21. Other Amounts Owed by You, Your Spouse, or Your Dependents
List all other amounts, not listed elsewhere in this financial statement, owed by you, your spouse, or your dependents.
Lender/Creditor’s Name, Address, and Telephone No.

Nature of Debt (if the result of a court judgment or settlement, provide court name and docket
number)

Lender/Creditor’s Relationship to You

Date Liability Was Incurred
Original Amount Owed
Current Amount Owed
Payment Schedule
/
/
$
$
(mm/dd/yyyy)
Lender/Creditor’s Name, Address, and Telephone No. Nature of Debt (if the result of a court judgment or settlement, provide court name and docket
number)

Lender/Creditor’s Relationship to You

Date Liability Was Incurred
/
/
(mm/dd/yyyy)

Original Amount Owed
$

Current Amount Owed
$

Payment Schedule

OTHER FINANCIAL INFORMATION
Item 22. Trusts and Escrows
List all funds and other assets that are being held in trust or escrow by any person or entity for you, your spouse, or your dependents. Include any legal
retainers being held on your behalf by legal counsel. 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.
Trustee or Escrow Agent’s Name & Address

Date Established
(mm/dd/yyyy)
/
/

Grantor

Beneficiaries

Present Market Value of Assets*
$

/

/

$

/

/

$

*If the market value of any asset is unknown, describe the asset and state its cost, if you know it.

Item 23. Transfers of Assets
List each person or entity to whom you have transferred, in the aggregate, more than $5,000 in funds or other assets during the previous five years by
loan, gift, sale, or other transfer (exclude ordinary and necessary living and business expenses paid to unrelated third parties). For each such person or
entity, state the total amount transferred during that period.
Transfer Date
(mm/dd/yyyy)
/

/

$

/

/

$

Property Transferred

Aggregate Value*
$

Transferee’s Name, Address, & Relationship

/

Type of Transfer
(e.g., Loan, Gift)

/

*If the market value of any asset is unknown, describe the asset and state its cost, if you know it.

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 24. Document Requests
Provide copies of the following documents with your completed Financial Statement.

Federal tax returns filed during the last three years by or on behalf of you, your spouse, or your dependents.
All applications for bank loans or other extensions of credit (other than credit cards) that you, your spouse, or your
dependents have submitted within the last two years, including by obtaining copies from lenders if necessary.
Item 9

For each bank account listed in Item 9, all account statements for the past 3 years.

Item 11

For each business entity listed in Item 11, provide (including by causing to be generated from accounting records) the
most recent balance sheet, tax return, annual income statement, the most recent year-to-date income statement, and all
general ledger files from account records.

Item 17

All appraisals that have been prepared for any property listed in Item 17, including appraisals done for insurance
purposes. You may exclude any category of property where the total appraised value of all property in that category is
less than $2,000.

Item 18

All appraisals that have been prepared for real property listed in Item 18.

Item 21

Documentation for all debts listed in Item 21.

Item 24

All executed documents for any trust or escrow listed in Item 22. Also provide any appraisals, including insurance
appraisals that have been done for any assets held by any such trust or in any such escrow.

SUMMARY FINANCIAL SCHEDULES
Item 25. Combined Balance Sheet for You, Your Spouse, and Your Dependents
Assets

Liabilities

Cash on Hand (Item 9)

$

Loans Against Publicly Traded Securities (Item 10)

$

Funds Held in Financial Institutions (Item 9)

$

Vehicles - Liens (Item 16)

$

U.S. Government Securities (Item 10)

$

Real Property – Encumbrances (Item 18)

$

Publicly Traded Securities (Item 10)

$

Credit Cards (Item 19)

$

Non-Public Business and Financial Interests (Item 11)

$

Taxes Payable (Item 20)

$

Amounts Owed to You (Item 12)

$

Amounts Owed by You (Item 21)

$

Life Insurance Policies (Item 13)

$

Other Liabilities (Itemize)

Deferred Income Arrangements (Item 14)

$

$

Vehicles (Item 16)

$

$

Other Personal Property (Item 17)

$

$

Real Property (Item 18)

$

$

Other Assets (Itemize)

$
$

$

$

$

$
Total Assets

$

$
Total Liabilities

$

Item 26. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents
Provide the current monthly income and expenses for you, your spouse, and your dependents. Do not include credit card payments separately; rather,
include credit card expenditures in the appropriate categories.
Income (State source of each item)
Salary - After Taxes
Source:
Fees, Commissions, and Royalties
Source:
Interest
Source:
Dividends and Capital Gains
Source:
Gross Rental Income
Source:
Profits from Sole Proprietorships
Source:
Distributions from Partnerships, S-Corporations,
and LLCs
Source:

$
$
$
$
$
$

Expenses
Mortgage or Rental Payments for Residence(s)
Property Taxes for Residence(s)
Rental Property Expenses, Including Mortgage Payments, Taxes,
and Insurance
Car or Other Vehicle Lease or Loan Payments
Food Expenses
Clothing Expenses

$
$
$
$
$
$

Utilities
$

$

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 27. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents (cont.)
Distributions from Trusts and Estates
Source:
Distributions from Deferred Income Arrangements
Source:
Social Security Payments

$

Other Transportation Expenses

Alimony/Child Support Received

$

Other Expenses (Itemize)

Gambling Income

$

$
$

Medical Expenses, Including Insurance
Other Insurance Premiums

$
$
$
$

Other Income (Itemize)

$
$

$

$
Total Income

$

$

$

$

Total Expenses

$

ATTACHMENTS
Item 28. 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)

___________________________________
Signature

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Federal Trade Commission Financial Statement of Individual Defendant

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 1 of 16 PageID #: 212

ATTACHMENT B

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 2 of 16 PageID #: 213
FEDERAL TRADE COMMISSION
FINANCIAL STATEMENT OF CORPORATE 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.

In completing this financial statement, “the corporation” refers not only to this corporation but also to each of its
predecessors that are not named defendants in this action.

4.

When an Item asks for information about assets or liabilities “held by the corporation,” include ALL such assets
and liabilities, located within the United States or elsewhere, held by the corporation or held by others for the
benefit of the corporation.

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 being continued.

6.

Type or print legibly.

7.

An officer of the corporation must sign and date the completed financial statement on the last page and initial
each page in the space provided in the lower right corner.

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.

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 3 of 16 PageID #: 214

BACKGROUND INFORMATION

Item 1.

General Information

Corporation’s Full Name ___________________________________________________________________________
Primary Business Address ______________________________________________________ From (Date) _________
Telephone No. _____________________________ Fax No. _____________________________
E-Mail Address________________________ Internet Home Page________________________
All other current addresses & previous addresses for past five years, including post office boxes and mail drops:
Address____________________________________________________________ From/Until____________________
Address____________________________________________________________ From/Until____________________
Address____________________________________________________________ From/Until____________________
All predecessor companies for past five years:
Name & Address _________________________________________________________ From/Until ______________
Name & Address _________________________________________________________ From/Until ______________
Name & Address _________________________________________________________ From/Until ______________

Item 2.

Legal Information

Federal Taxpayer ID No. _________________________ State & Date of Incorporation _________________________
State Tax ID No. ____________________ State ________________ Profit or Not For Profit _____________________
Corporation’s Present Status: Active ________________ Inactive _______________ Dissolved __________________
If Dissolved: Date dissolved _________________________ By Whom ______________________________________
Reasons _________________________________________________________________________________________
Fiscal Year-End (Mo./Day) ________________ Corporation’s Business Activities _____________________________

Item 3.

Registered Agent

Name of Registered Agent __________________________________________________________________________
Address __________________________________________________________ Telephone No. __________________

Page 2

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 4 of 16 PageID #: 215

Item 4.

Principal Stockholders

List all persons and entities that own at least 5% of the corporation’s stock.
% Owned

Name & Address

_________________________________________________________________________________ ______________
_________________________________________________________________________________ ______________
_________________________________________________________________________________ ______________
_________________________________________________________________________________ ______________

Item 5.

Board Members

List all members of the corporation’s Board of Directors.
Name & Address

% Owned

Term (From/Until)

____________________________________________________________________ __________ _________________
____________________________________________________________________ __________ _________________
____________________________________________________________________ __________ _________________
____________________________________________________________________ __________ _________________
____________________________________________________________________ __________ _________________

Item 6.

Officers

List all of the corporation’s officers, including de facto officers (individuals with significant management responsibility
whose titles do not reflect the nature of their positions).
Name & Address

% Owned

_______________________________________________________________________________ ________________
_______________________________________________________________________________ ________________
_______________________________________________________________________________ ________________
_______________________________________________________________________________ ________________
_______________________________________________________________________________ ________________

Page 3

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 5 of 16 PageID #: 216

Item 7.

Businesses Related to the Corporation

List all corporations, partnerships, and other business entities in which this corporation has an ownership interest.
Name & Address

Business Activities

% Owned

___________________________________________________________________ ___________________ _________
___________________________________________________________________ ___________________ _________
___________________________________________________________________ ___________________ _________
State which of these businesses, if any, has ever transacted business with the corporation _______________________
________________________________________________________________________________________________

Item 8.

Businesses Related to Individuals

List all corporations, partnerships, and other business entities in which the corporation’s principal stockholders, board
members, or officers (i.e., the individuals listed in Items 4 - 6 above) have an ownership interest.
Business Name & Address

Individual’s Name

Business Activities

% Owned

__________________ __________________________________________________ __________________ ________
__________________ __________________________________________________ __________________ ________
__________________ __________________________________________________ __________________ ________
State which of these businesses, if any, have ever transacted business with the corporation _______________________
________________________________________________________________________________________________

Item 9.

Related Individuals

List all related individuals with whom the corporation has had any business transactions during the three previous fiscal
years and current fiscal year-to-date. A “related individual” is a spouse, sibling, parent, or child of the principal
stockholders, board members, and officers (i.e., the individuals listed in Items 4 - 6 above).
Name and Address

Relationship

Business Activities

_________________________________________________________ _________________ ______________________
_________________________________________________________ _________________ ______________________
_________________________________________________________ _________________ ______________________

Page 4

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 6 of 16 PageID #: 217

Item 10.

Outside Accountants

List all outside accountants retained by the corporation during the last three years.
Firm Name

Name

Address

CPA/PA?

____________________ ______________________ ________________________________________ ____________
____________________ ______________________ ________________________________________ ____________
____________________ ______________________ ________________________________________ ____________
____________________ ______________________ ________________________________________ ____________
____________________ ______________________ ________________________________________ ____________

Item 11.

Corporation’s Recordkeeping

List all individuals within the corporation with responsibility for keeping the corporation’s financial books and records for
the last three years.
Position(s) Held

Name, Address, & Telephone Number

____________________________________________________________________________ ___________________
____________________________________________________________________________ ___________________
____________________________________________________________________________ ___________________
____________________________________________________________________________ ___________________

Item 12.

Attorneys

List all attorneys retained by the corporation during the last three years.
Name

Firm Name

Address

____________________ ___________________________ ________________________________________________
____________________ ___________________________ ________________________________________________
____________________ ___________________________ ________________________________________________
____________________ ___________________________ ________________________________________________
____________________ ___________________________ ________________________________________________

Page 5

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 7 of 16 PageID #: 218

Item 13.

Pending Lawsuits Filed by the Corporation

List all pending lawsuits that have been filed by the corporation in court or before an administrative agency. (List
lawsuits that resulted in final judgments or settlements in favor of the corporation in Item 25).
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________

Page 6

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 8 of 16 PageID #: 219

Item 14.

Current Lawsuits Filed Against the Corporation

List all pending lawsuits that have been filed against the corporation in court or before an administrative agency. (List
lawsuits that resulted in final judgments, settlements, or orders in Items 26 - 27).
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address___________________________________________________________________________
Docket No._________________ Relief Requested____________________ Nature of Lawsuit____________________
____________________________________ Status______________________________________________________

Page 7

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 9 of 16 PageID #: 220

Item 15.

Bankruptcy Information

List all state insolvency and federal bankruptcy proceedings involving the corporation.
Commencement Date _________________ Termination Date _________________ Docket No. __________________
If State Court: Court & County _______________________ If Federal Court: District __________________________
Disposition ______________________________________________________________________________________

Item 16.

Safe Deposit Boxes

List all safe deposit boxes, located within the United States or elsewhere, held by the corporation, or held by others for the
benefit of the corporation. On a separate page, describe the contents of each box.
Owner’s Name

Name & Address of Depository Institution

Box No.

__________________ ___________________________________________________________________ __________
__________________ ___________________________________________________________________ __________
__________________ ___________________________________________________________________ __________
__________________ ___________________________________________________________________ __________
__________________ ___________________________________________________________________ __________

FINANCIAL INFORMATION
REMINDER: When an Item asks for information about assets or liabilities “held by the corporation,” include
ALL such assets and liabilities, located within the United States or elsewhere, held by the corporation or held by
others for the benefit of the corporation.
Item 17.

Tax Returns

List all federal and state corporate tax returns filed for the last three complete fiscal years. Attach copies of all returns.
Federal/
State/Both

Tax Year

Tax Due
Federal

Tax Paid
Federal

Tax Due
State

Tax Paid
State

Preparer’s Name

___________ __________ $_________ $_________ $__________ $__________ ______________________________
___________ __________ $_________ $_________ $__________ $__________ ______________________________
___________ __________ $_________ $_________ $__________ $__________ ______________________________

Page 8

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 10 of 16 PageID #: 221

Item 18.

Financial Statements

List all financial statements that were prepared for the corporation’s last three complete fiscal years and for the current
fiscal year-to-date. Attach copies of all statements, providing audited statements if available.
Year

Balance Sheet

Profit & Loss Statement

Cash Flow Statement Changes in Owner’s Equity Audited?

_________ _____________ ______________________ __________________ _______________________ ________
_________ _____________ ______________________ __________________ _______________________ ________
_________ _____________ ______________________ __________________ _______________________ ________
_________ _____________ ______________________ __________________ _______________________ ________
Item 19.

Financial Summary

For each of the last three complete fiscal years and for the current fiscal year-to-date for which the corporation has not
provided a profit and loss statement in accordance with Item 18 above, provide the following summary financial
information.
Current Year-to-Date

1 Year Ago

2 Years Ago

3 Years Ago

Gross Revenue

$_________________

$_______________

$_______________

$_______________

Expenses

$_________________

$_______________

$_______________

$_______________

Net Profit After Taxes

$_________________

$_______________

$_______________

$_______________

Payables

$_________________

Receivables

$_________________

Item 20.

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 the corporation. The term “cash” includes currency and uncashed checks.
Cash on Hand $_________________________ Cash Held for the Corporation’s Benefit $_______________________
Name & Address of Financial Institution

Signator(s) on Account

Account No.

Current
Balance
_____________________________________ _______________________________ ______________ $___________
_____________________________________ _______________________________ ______________ $___________
_____________________________________ _______________________________ ______________ $___________
_____________________________________ _______________________________ ______________ $___________

Page 9

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 11 of 16 PageID #: 222

Item 21.

Government Obligations and Publicly Traded Securities

List all U.S. Government obligations, including but not limited to, savings bonds, treasury bills, or treasury notes, held by
the corporation. Also 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 the corporation.
Issuer _________________________________ Type of Security/Obligation __________________________________
No. of Units Owned __________ Current Fair Market Value $__________________ Maturity Date _______________
Issuer _________________________________ Type of Security/Obligation __________________________________
No. of Units Owned __________ Current Fair Market Value $__________________ Maturity Date _______________

Item 22.

Real Estate

List all real estate, including leaseholds in excess of five years, held by the corporation.
Type of Property________________________________ Property’s Location__________________________________
Name(s) on Title and Ownership Percentages___________________________________________________________
Current Value $____________________ 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___________________________________________________________
Current Value $____________________ 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

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 12 of 16 PageID #: 223

Item 23.

Other Assets

List all other property, by category, with an estimated value of $2,500 or more, held by the corporation, including but not
limited to, inventory, machinery, equipment, furniture, vehicles, customer lists, computer software, patents, and other
intellectual property.
Property Category

Property Location

Acquisition
Cost

Current
Value

____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________
____________________________ _____________________________________________ $__________ $_________

Item 24.

Trusts and Escrows

List all persons and other entities holding funds or other assets that are in escrow or in trust for the corporation.
Trustee or Escrow Agent’s
Name & Address

Description and Location of Assets

Present Market
Value of Assets

______________________________________ _______________________________________ $_________________
______________________________________ _______________________________________ $_________________
______________________________________ _______________________________________ $_________________
______________________________________ _______________________________________ $_________________
______________________________________ _______________________________________ $_________________
______________________________________ _______________________________________ $_________________
______________________________________ _______________________________________ $_________________

Page 11

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 13 of 16 PageID #: 224

Item 25.

Monetary Judgments and Settlements Owed To the Corporation

List all monetary judgments and settlements, recorded and unrecorded, owed to the corporation.
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 $____________

Item 26.

Monetary Judgments and Settlements Owed By the Corporation

List all monetary judgments and settlements, recorded and unrecorded, owed by the corporation.
Opposing Party’s Name & Address___________________________________________________________________
Court’s Name & Address____________________________________________________ Docket No._____________
Nature of Lawsuit_______________________________________ Date______________ Amount $______________
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 $____________
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 12

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 14 of 16 PageID #: 225

Item 27.

Government Orders and Settlements

List all existing orders and settlements between the corporation and any federal or state government entities.
Name of Agency ___________________________________________ Contact Person __________________________
Address _____________________________________________________________ Telephone No. _______________
Agreement Date ______________ Nature of Agreement __________________________________________________

Item 28.

Credit Cards

List all of the corporation’s credit cards and store charge accounts and the individuals authorized to use them.
Name of Credit Card or Store

Names of Authorized Users and Positions Held

__________________________________________ _____________________________________________________
__________________________________________ _____________________________________________________
__________________________________________ _____________________________________________________
__________________________________________ _____________________________________________________
__________________________________________ _____________________________________________________

Item 29.

Compensation of Employees

List all compensation and other benefits received from the corporation by the five most highly compensated employees,
independent contractors, and consultants (other than those individuals listed in Items 5 and 6 above), for the two previous
fiscal years and current fiscal year-to-date. “Compensation” includes, but is not limited to, salaries, commissions,
consulting fees, bonuses, dividends, distributions, royalties, pensions, and profit sharing plans. “Other benefits” include,
but are not limited to, loans, loan payments, rent, car payments, and insurance premiums, whether paid directly to the
individuals, or paid to others on their behalf.
Name/Position

Current Fiscal
Year-to-Date

1 Year Ago

2 Years Ago

Compensation or
Type of Benefits

_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________

Page 13

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 15 of 16 PageID #: 226

Item 30.

Compensation of Board Members and Officers

List all compensation and other benefits received from the corporation by each person listed in Items 5 and 6, for the
current fiscal year-to-date and the two previous fiscal years. “Compensation” includes, but is not limited to, salaries,
commissions, consulting fees, dividends, distributions, royalties, pensions, and profit sharing plans. “Other benefits”
include, but are not limited to, loans, loan payments, rent, car payments, and insurance premiums, whether paid directly to
the individuals, or paid to others on their behalf.
Name/Position

Current Fiscal
Year-to-Date

1 Year Ago

2 Years Ago

Compensation or
Type of Benefits

_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
_____________________________ $____________ $___________ $____________ ___________________________
Item 31.

Transfers of Assets Including Cash and Property

List all transfers of assets over $2,500 made by the corporation, other than in the ordinary course of business, during the
previous three years, by loan, gift, sale, or other transfer.
Transferee’s Name, Address, & Relationship

Property
Transferred

Aggregate
Value

Transfer
Date

Type of Transfer
(e.g., Loan, Gift)

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________

______________________________________ ________________ $____________ __________ _________________

Page 14

Initials __________

Case 1:12-cv-05890-NGG-RML Document 9-2 Filed 11/29/12 Page 16 of 16 PageID #: 227

Item 32.

Documents Attached to the Financial Statement

List all documents that are being submitted with the 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)

_____________________________________________________
Signature

_____________________________________________________
Corporate Position

Page 15

Initials __________