CERTIFICATE OF INTERESTED PERSONS AND CORPORATE DISCLOSURE STATEMENT I hereby disclose the following pursuant to this Court's Order on Interested Persons And Corporate Disclosure Statement: 1.) the name of each person, attorney, association of persons, firm, law firm, partnership, and corporation that has or may have an interest in a party to this action or in the outcome of this action, including subsidiaries, conglomerates, affiliates, parent corporations, publicly-traded companies that own 10% or more of a party's stock, and all other identifiable legal entities related to a party:3 [insert list] 2.) the name of every other entity whose publicly-traded stock, equity, or debt may be substantially affected by the outcome of the proceedings:4 [insert list] 3.) the name of every other entity which is likely to be an active participant in the proceedings, including the debtor and members of the creditors' committee (or if no creditors' committee the 20 largest unsecured creditors):5 [insert list] 4.) the name of each victim (individual and corporate), including every person who may be entitled to restitution:6 [insert list] 5.) Check one of the following: _____ a. I certify that I am unaware of any actual or potential conflict of interest involving the District Judge and Magistrate Judge assigned to this case and will immediately notify the Court in writing upon learning of any such conflict. -or_____ b. I certify that I am aware of a conflict or basis of recusal of the District Judge or Magistrate Judge as follows: (explain). [Date] [Certificate of Service] _____________________________ [Counsel of Record or Pro Se Party] [Address and Telephone] This disclosure is to be given in all cases. A party should not routinely list an assigned District Judge or Magistrate Judge as an "interested person" absent some non-judicial interest. 4 5 6 3 This disclosure is to be given in all cases. This disclosure is to be given in bankruptcy cases. This disclosure is to be given in criminal and civil cases. -2American LegalNet, Inc. www.FormsWorkFlow.com