OPROB 8A (03/04) U.S. PROBATION OFFICE SUPERVISION REPORT FOR ORGANIZATIONS FOR THE MONTH You are instructed to provide information below about the organization's activities which occurred only during the period stated above. Fill out completely, leaving no blanks (attach separate sheet if necessary). If an item is inapplicable, state "N/A." Name of Organization: D/B/As Court Name (if different): PART A: NATURE OF THE ORGANIZATION Street Address: City, State, Zip Code: Phone: Mailing Address (if different): Web Address: Type of organization (e.g., corporation, partnership): Principal business purpose: Name and title of organization's representative to the court and probation office: Address (if different): Phone: List Names of All Officers Officer's Position Check if Felony Record E-Mail Address: E-Mail Address: Any change in street or mailing address? If yes, date of change: Reason for change: Yes No Name and position of principal employee or officer responsible for the accounting records: Address (if different): Phone: E-Mail Address: Did the organization dissolve or change the name under which it does business? Explain: Yes If yes, date: Name of outside public accountant: Address: Phone: E-Mail Address: Are all the organization's business licenses up to date? Yes No If no, explain: Have any licenses been revoked or suspended? Yes No If yes, explain: PART B: FINANCIAL ACTIVITY Total Income: Total Expenses: Net Income $ $ $ Investor: Amount of Investment $ Investor: Amount of income from foreign countries: Identify foreign countries: (Attach any income statement, balance sheet, or statement of cash flow completed during the period.) $ Amount of Investment $ Investor: Amount of Investment $ Capital Investments: American LegalNet, Inc. www.FormsWorkFlow.com OPROB 8A (03/04) PART B. FINANCIAL ACTIVITY (Continued) Checking Accounts: Bank: Account No.: Balance: Bank: Account No.: Balance: Bank: Account No.: Balance: $ $ $ Bank: Account No.: Balance: Bank: Account No.: Balance: Bank: Account No.: Balance: $ $ $ Savings or Investments: Page 2 Did the organization own or have any financial interest or signatory authority over any foreign financial accounts or organizations? Yes No If yes, explain and identify which countries: Did the organization experience a substantial increase/decrease in profits? Yes No If yes, explain: Was the organization involved in any bankruptcy proceedings? Yes Court: No Docket No. Did the organization file any tax return, sales tax report, or estimated voucher? Yes No If yes, identify documents and tax periods: (Attach a copy of bankruptcy petition and/or order.) (Attach copies of documents.) Has the organization filed an annual report? (If yes, attach a copy.) or receipts.) DATE DESCRIPTION OF SALES/PURCHASE $ $ $ $ PART C. COMPLIANCE WITH CONDITIONS OF SUPERVISION Was the organization a plaintiff, respondent, or defendant in any criminal prosecution, civil litigation, or administrative proceeding? If yes, explain (include court and docket number): Yes No AMOUNT METHOD OF PAYMENT Yes No List all purchases or sales over $5,000 not associated with the daily operation of the business: (Provide copies of all purchase orders, sales agreements, Was the organization contacted by any law enforcement/regulatory agency? Yes No If yes, explain: Were any officers contacted or arrested by a law enforcement officer for any reason relating to the organization? If yes, explain (include date of arrest): Yes No Describe what action was taken by the organization to prevent or detect violations of the law and/or to maintain a compliance program. American LegalNet, Inc. www.FormsWorkFlow.com OPROB 8A (03/04) PART C. COMPLIANCE WITH CONDITIONS OF SUPERVISION (Continued) Has there been any adverse action(s) and/or order(s) taken against the organization from any regulatory agency? Yes No If yes, explain: Page 3 Did any officers or agents travel to a foreign country on behalf of the country or organization? Countries: Purpose: Yes No If yes: Describe what action was taken to notify employees, stockholders, victims, or the public regarding the organization's conviction and action it is taking to prevent reoccurrence: Does the organization owe a special assessment, fine, restitution, or cost of supervision? Yes No Is the organization required to perform community service? Yes No If yes: Name of agency where performed: (If yes, submit receipt(s) for the payment(s) made during this period.) Nature of service: Number of hours completed during this period: Amount paid in contributions: $ WARNING: ANY FALSE STATEMENT MAY RESULT IN REVOCATION OF THE ORGANIZATION'S TERM OF PROBATION. ALSO, ANY FALSE STATEMENT BY THE SIGNATORY ON THIS REPORT MAY RESULT IN 5 YEARS IMPRISONMENT, A $250,000 FINE, OR BOTH. (18 U.S.C. § 1001) I CERTIFY THAT ALL INFORMATION FURNISHED IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Signature Date Title of representative and position with the organization For offical use only REMARKS: For official use only RECEIVED: Mail CV U.S. Probation Officer Date RETURN TO: OV American LegalNet, Inc. www.FormsWorkFlow.com