PROB 48(Rev. 07/13)Last NameFirst NameMiddle NameSocial SecurityNumber Instructions for Completing Net Worth 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.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 Statement in its entirety. You must answer 223None224 to any item that is notapplicable to your financial condition. Attach additional pages if you need more space for any item. All entriesmust be accompanied by supporting documentation (see Request for Net Worth Statement Financial Records(Prob. 48A)). Initial and date each page (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 48Page 2 of (Rev. 07/13) Last Name -NET WORTH STATEMENT NOTE: I = Individual J = Joint S = Spouse/Significant Other D = DependentSection A ASSETSBANK ACCOUNTS (Include all personal and businesses checking and savings accounts, credit unions, money markets, certificates ofdeposit, IRA and KEOGH accounts, ROTH IRA222s, Thrift Savings, 401K, etc.)I/JName of InstitutionAddressType ofAccountAccountNumberPersonal orCommercialBalanceS/DSection B SECURITIES (Include all stocks in public corporations, stocks in businesses you own or have an interest in, bonds, mutual funds, U.S. Government securities, etc.)I/JName and Kind of SecurityLocation of SecurityNumber ofUnitsFair MarketValueS/DSection C MONEY OWED TO YOU BY OTHERS (Include all money owed to you by any person or entity.)I/JName and Address ofAmountReason OwedDate MoneyRelationshipMonthlyIs DebtS/DDebtorOwed to Youto YouLoanedto Debtor(if any)Paymentor DateFullPaymentExpectedCollectible ?InitialsDate American LegalNet, Inc. www.FormsWorkFlow.com PROB 48Page 3 of (Rev. 07/13) Last Name -Section D LIFE INSURANCE (Include type of policy [whole life, variable, or term], face amount [the stated amount of coverage] and cash surrender value [the value of the investment portion of a whole life or variable policy.])I/JName and Address ofPolicyType ofFaceCashAmountAmountS/DCompany and Nameof BeneficiaryNumberPolicyAmountSurrenderValueBorrowedYou CanBorrowSection E SAFE DEPOSIT BOXES OR STORAGE SPACE FACILITY (Include all safe deposit boxes or storage space you rent or places you have access to in which others are holding assets or items belonging to you.)I/JName and Addressof Box or Facility LocationBox Numberor SpaceContentsFair Market ValueS/DSection F MOTOR VEHICLES (Include all cars, trucks, mobile homes, motorcycles, all terrain vehicles, boats, airplanes, etc.)I/JYear, Make & LicenseMileageLoan/LeaseDate Loan/LeaseMonthlyFair MarketS/DNumber/VehicleIdentification NumberBalance(if any)Will be Paid Offor EndsPaymentValueSection G REAL ESTATE (Include property, parcels, lots, timeshares, and developed land with buildings.)I/JReal Estate AddressPurchasePurchaseMortgageDateMonthlyFair MarketS/D(include county and state)/Mortgage Companyor Lien HolderDatePriceBalance(if any)MortgageWill be PaidOffPaymentValueSection H MORTGAGE LOANS OWED TO YOU (Include name, address, and relationship [if any] to the mortgagee [the party that bought the real estate you sold and is making payments to you].)I/JMortgagee (name & address)/MortgageDate MortgageBalloonMonthlyIs DebtS/DRelationship to MortgageeBalanceWill be PaidOffPayment?If Yes, Date?PaymentCollectible?InitialsDate American LegalNet, Inc. www.FormsWorkFlow.com PROB 48Page 4 of (Rev. 07/13) Last Name -Section I OTHER ASSETS (Include any cash on hand, jewelry, art, paintings, coin collections, stamp collections, musical instruments, collectibles,antiques, home furnishings, copyrights, patents, etc.)I/JDescriptionLoanDate LoanMonthlyWhere is AssetFair MarketS/DBalance(if any)Will be PaidOffPaymentLocated?ValueSection J ANTICIPATED ASSETS (Include any assets you expect to receive or control from lawsuits for compensation or damages, profit sharing, pension plans, inheritance, wills, or as an executor or administrator of any succession or estate.)I/JAmount Received orDateReason You Expect ThisName and Address of Person or CompanyS/DExpected to ReceiveExpected toReceiveThat Can Verify This (e.g., attorney, financialinstitution, executor) TRUST ASSETS (Include all trusts in which you are a grantor or donor [the person who establishes the trust], the trustee or fiduciary [who controls the trust assets and income or the beneficiary who has or will receive benefits from the trust].)I/JName of Trust/Value ofYour Annual Income From TrustYour Interest in Trust AssetsS/DTaxpayer ID#Trust Section K BUSINESS HOLDINGS (Include all businesses in which you have an ownership interest or with which you had an affiliation within the last three years; e.g., self-employed sole proprietor, officer, shareholder, board member, partner, associate, etc.) Complete Section N (attach additional pages, if necessary).I/JName and AddressType ofIndustry ofDateCapitalYourSale Price orS/Dof Business/Taxpayer I.D.#BusinessEntityBusinessBusinessStartedInvestmentto StartOwnershipInterestPercentageFair MarketValue of YourInterest InitialsDate American LegalNet, Inc. www.FormsWorkFlow.com PROB 48Page 5 of (Rev. 07/13) Last Name -Section L INCOME TAX RETURNSType of Income Tax Return FiledLast Filing YearYears of Last 5 Income Tax ReturnsYou Will Submit to the ProbationOfficer Individual (Form 1040) Partnership/Limited Liability Company (Form 1065) Corporation (Form 1120) S Corporation (Form 1120S)Section M TRANSFER OF ASSETS (Include any assets you have transferred or sold since the date of your arrest with a cost or fair market value of more than $1,000.00. Also list any assets that someone else is holding on your behalf.)I/JDescription of Asset/Date ofOriginalAmount YouName ofSale Price orS/DReasonTransferred/SoldTransfer/SaleCostReceived, ifAnyPurchaser orPerson Holdingthe AssetFair Market Valueat TransferSection N NAMES OF SHAREHOLDERS OR PARTNERS (Include all shareholders, officers, and/or partners, indicating each respective ownership interest.)Name of BusinessNames of Shareholders/PartnersOwnership InterestPercentageInitialsDate American LegalNet, Inc. www.FormsWorkFlow.com PROB 48Page 6 of (Rev. 07/13) Last Name -Section O ASSETS YOU WILL LIQUIDATE (Include all assets you intend to liquidate to satisfy any criminal monetary penalties that may be imposed.)Asset DescriptionEstimated Valueof AssetDate You WillLiquidateCurrent Location of Asset(if real property, county and state)Section P PROSPECT OF INCREASE IN ASSETS (Give a general statement of the prospective increase of the value of any asset you own.)InitialsDate American LegalNet, Inc. www.FormsWorkFlow.com PROB 48Page 7 of (Rev. 07/13) Last Name -Section ALIABILITIES CHARGE ACCOUNTS AND LINES