IN THE CIRCUIT COURT OF Judge or Division: COUNTY, MISSOURI Case Number: (Date File Stamp) General Affidavit-Questionnaire (Bondsman) 1. Name/Present Address 3. How long at this address? 4. Your age 5. 2. Previous Address 6. Marital Status Married Divorced Name of Spouse Single 7. Have you ever been convicted of a criminal offense in any state or federal court or any foreign country court? Yes No (Convictions of municipal violations are not included.) 8. Are you an attorney at law admitted to practice by the Supreme Court of Missouri? Yes No 9. Have you ever been licensed as an attorney and later disbarred or suspended? Yes No 10 Are you a party upon any bail bond in any court of this state or any other state or territory of the United States, which after being forfeited, remains unpaid or unsatisfied? Yes No 11. Inventory of all real estate of which you are sole legal or equitable owner. (attach additional sheet if more space is needed) Tract One Tract Two A. Legal description A. Legal description B. City, zone, street and street number B. City, zone, street and street number C. Description of all improvements C. Description of all improvements D. Present market value (est.) D Present market value (est.) $ F E Assessed valuation $ Incumbrances with amounts and names of persons holding the same (mortgages, mechanics' liens, tax liens and other liens) OSCA (4-95) CR90 $ F. 1 of 2 E. Assessed valuation $ Incumbrances with amounts and names of persons holding the same (mortgages, mechanics' liens, tax liens and other liens) Rules 33.17, 33.20 American LegalNet, Inc. www.USCourtForms.com Tract Three Tract Four A. Legal description A. Legal description B. City, zone, street and street number B. City, zone, street and street number C. Description of all improvements C. Description of all improvements D. Present market value (est. $ Assessed valuation $ D. Present market value (est.) $ F. Incumbrances with amounts and names of persons holding the same (mortgages, mechanics; liens, tax liens, and other liens) F. Incumbrances with amounts and names of persons holding the same (mortgages, mechanics, liens, tax liens, and other liens) E. E. Assessed Valuation $ Note: Do not list any property which you and your wife own as tenants by the entirety or as joint tenants and do not list any property in which you own only a life estate or a remainder. 12. If bond is to be signed by both husband and wife as sureties, attached a separate sheet providing the same information required by question number 11. Yes No Attached 14 List any personal property and indicate if any of the property is subject to any encumbrance or liens, state the nature and amount of the same and by whom held. (Provide on a separate attached sheet.) Yes No Attached 16. Has any Federal tax lien been filed against you? Yes No 13. If any of the real estate listed on this questionnaire is subject to a lease for longer than two years, state the name of the lessee, term o f lease and amount of rental on a Yes No separate sheet. Attached $ $ 15. List all bail bonds upon which you are surety and are now outstanding. Specify amount of each bond, name of defendant, the offense charged and the court in which the charge is pending. (Provide on a separate attached sheet.) Attached Yes No 17. State the appropriate amount of your outstanding debts, other than those listed above. 18. Have you or anyone for you or in your behalf received orbeen promised any consideration or security suretyship? Yes No If yes, provide the nature and amount of the consideration/security and the name of the person(s) by whom such promise was made or from whom such security or consideration was received. (Attach additional sheet if necessary.) Date OSCA (4-95) CR90 Signature(s) 2 of 2 Rules 33.17, 33.20 American LegalNet, Inc. www.USCourtForms.com