PROB 48EZ(Rev. 07/13)Last NameFirst NameMiddle NameSocial SecurityNumber Instructions for Completing Net Worth Short Form StatementHaving been convicted in the United States District Court, you are required to prepare and file with theprobation officer an affidavit fully describing your financial resources, including a complete listing of all assetsyou own or control as of this date and any assets you have transferred or sold since your arrest. Amendmentswere made to 18 U.S.C. 247247 3663(a)(1)(B)(i), 3664(d)(3), and 3664(f)(2), and Rule 32(b)(4)(F) to clarify thatthe assets owned, jointly owned, or controlled by an offender, and liabilities are all relevant to the court222sdecision regarding the ability to pay. Your Net Worth Statement should include assets or debts that are yoursalone (I-Individual), assets or debts that are jointly (J-Joint) held by you and a spouse or significant other, assetsor debts that are held by a spouse or significant other (S-Spouse or Significant Other) that you enjoy the benefitsof or make occasional contributions toward, and assets or debts that are held by a dependent (D-Dependent)that you enjoy the benefits of or make occasional contributions toward. The court may require relating to suchother factors as the court deems appropriate (see 18 U.S.C. 247 3664(d)(3)).If you are placed on probation or supervised release (or other types of supervision), you may be periodicallyrequired to provide updated information fully describing your financial resources and those of your dependents,as described above, to keep a probation officer informed concerning compliance with any condition ofsupervision, including the payment of any criminal monetary penalties imposed by the court (see 18 U.S.C.247 3603).Please complete the Net Worth Short Form Statement in its entirety. You must answer 223None224 to any item thatis not applicable to your financial condition. Attach additional pages if you need more space for any item. Allentries must be accompanied by supporting documentation (see Request for Net Worth Statement FinancialRecords (Prob. 48A)). Sign and date Page 2 (including any attached pages). Also, sign, date, and attach theDeclaration of Defendant or Offender Net Worth & Cash Flow Statements (Prob. 48D). American LegalNet, Inc. www.FormsWorkFlow.com PROB 48EZPage 2(Rev. 07/13)NET WORTH SHORT FORM STATEMENT NOTE: I = Individual J = Joint S = Spouse/Significant Other D = DependentASSETSInclude below all cash on hand, bank accounts, securities, money owed to you by others, life insurance, safe deposit boxes or storagefacilities, motor vehicles, real estate, mortgage loans owed to you, other assets, anticipated assets, and business holdings.I/JType of AssetLocation of Asset (e.g., bank,Fair Market or Actual ValueS/D(e.g., cash, bank account) including account number)Include below all assets transferred or sold since your arrest with a cost or fair market value of more than $1,000.00, or assets thatsomeone else is holding on your behalf.I/JType of AssetDate Sold or TransferredFair Market or Actual ValueS/DIdentify below any assets you will liquidate to satisfy any criminal monetary penalty that may be imposed, and/or describe theprospect of increase in assets.I/JType of AssetFair Market or Actual ValueS/DLIABILITIESInclude below all charge accounts and lines of credit, mortgage balances, other debts, civil suits, and bankruptcy filings.I/JType of Debt (e.g., credit card)Debt Owed to (e.g., name,Balance OutstandingS/Daccount number)SignatureDate American LegalNet, Inc. www.FormsWorkFlow.com