PROB 48a (Rev. 1/10) Page 1 of 2 REQUEST FOR NET WORTH STATEMENT FINANCIAL RECORDS DEFENDANTS FULL NAME DOCKET NUMBER All entries on the Net Worth Statement must be accompanied by supporting documentation. Provide the probation officer with all records listed below that are applicable to your financial statements, along with your completed Net Worth Statement by the close of business on: ASSETS Section A - Bank Accounts Section J - Anticipated Assets -- Most recent bank account statements (e.g., checking, savings, credit -- Copy of documentation to verify future receipt of anticipated asset, (e. g., claim or lawsuit filings, profit sharing plan and current statement, union, money market, brokerage, Certificate of Deposit, or savings pension plan and current statement inheritance documents, copy of all bonds) for a three-month period, along with canceled checks. trusts, trust income tax returns), and most recent accounting reflecting the value of your interest and income from the trust. Section B - Securities -- Most recent securities account statements (e.g., brokerage, annuities, Section K - Business Holdings life insurance, IRA, KEOGH, 401 K, or thrift savings account) for a three-- In addition to providing the information requested in Section K and month period. completing Section N, provide copies of all income tax returns for each business you had an ownership interest in (e.g., shareholder, partner, Section C - Notes & Accounts Receivable proprietor) or an affiliation with (e.g., officer, director, board member, agent, associate) within the last five years. Also provide all financial -- Copy of signed note receivable. statements for each business, prepared by you or your accountant, within the past five years. Section D - Life Insurance -- Copy of all life insurance policies (e.g., whole life, variable life, term) and recent statements. Section E - Safe Deposit Boxes or Storage Facilities Business Accounts Receivable -- Copy of current month's billing statements that verify business accounts receivable. -- Copy of most recent rental invoice for all safe deposit boxes or storage Business Accounts Payable facility rentals within the past year, including receipts or verification of content value. -- Copy of current month's vendor invoices that verify business accounts payable. Section F - Motor Vehicles Section L - Income Tax Returns -- Copy of vehicle registration and title for all vehicles owned or leased. -- Copy of the five most recent years' income tax returns filed for: Section G - Real Estate Individual (Form 1040), Partnership (Form 1065), Corporation (Form 1120), S Corporation (Form 1120S), and Limited Liability Company (Form -- Copy of purchase agreement, deeds, and escrow statement for all real 1065). Be sure to include all related schedules and forms. Provide a property. written explanation for any returns not filed. Section H - Mortgage Loans Owed to You -- Copy of the sales agreement and escrow statement for all real property. Section I - Other Assets Section M - Transfer of Assets -- Copy of the bill of sale, documentation of funds received from sale (e.g., a personal or business check, cashiers check or money order), copy of vehicle registration and title of sold vehicle, and escrow closing statements for any real estate sold since the ate of your arrest. -- Copy of purchase invoice and appraisal (if already previously Section N - Names of Shareholders or Partners obtained), and documentation to verify the fair market value of the asset. -- Copy of Articles of Incorporation corporations you own or have an interest in. Copy of partnership agreement for all partnerships you have an ownership interest in. American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR NET WORTH STATEMENT FINANCIAL RECORDS (cont.) LIABILITIES Section A - Charge Accounts -- Copy of most current billing statement for all charge accounts (e.g., credit cards, revolving charge cards, and department store cards) and lines of credit (e.g., bank line of credit). Section B - Other Debts -- Copy of all notes payable, mortgage loans, current statement of delinquent taxes due, and statements documenting child support/alimony obligations and payment history. Section C - Party to Civil Suit -- Copy of all civil suit filings and judgments. Section D - Bankruptcy Filings -- Copy of all bankruptcy filings including petition, financial statements submitted, final judgment and order of discharge. OTHER RECORDS REQUESTED: Page 2 of 2 ADDITIONAL INSTRUCTIONS: Office Locations: Office Phone: American LegalNet, Inc. www.FormsWorkFlow.com