Form Rea-Amc-02- Biographical Affidavit To Support Form Rea-Amc-02 Page 3
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416. List your residences for the last ten (10) years starting with your current address, giving:
Beginning/Ending
State/
Dates (MM/YY)
Address
City
Province
Country
Postal Code
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
Note:
Dates provided in response to this question may be approximate, except for current address. Parties using this form understand that
there could be an overlap of dates when transitioning from one address to another.
17. In responding to the following, if the record has been sealed or expunged, and the affiant has personally verified that the record was
sealed or expunged, the affiant may respond “no” to the question. Have you ever:
a.
Been refused an occupational, professional, or vocational license or permit by any regulatory authority, or any public administrative,
or governmental licensing agency?
Yes
No ______
b.
Had any occupational, professional, or vocational license or permit you hold or have held, been subject to any judicial,
administrative, regulatory, or disciplinary action?
Yes
No ______
c.
Been placed on probation or had a fine levied against you or your occupational, professional, or vocational license or permit in any
judicial, administrative, regulatory, or disciplinary action?
Yes
No ______
d.
Been charged with, or indicted for, any criminal offense(s) other than civil traffic offenses?
Yes
No ______
e.
Pled guilty, or nolo contendere, or been convicted of, any criminal offense(s) other than civil traffic offenses?
Yes
No ______
f.
Had adjudication of guilt withheld, had a sentence imposed or suspended, had pronouncement of a sentence suspended, or been
pardoned, fined, or placed on probation, for any criminal offense(s) other than civil traffic offenses?
Yes
No ______
g.
Been, within the last ten (10) years, a party to any civil action involving dishonesty, breach of trust, or a financial dispute? ________
Yes
No ______
h.
Had a finding made by the Comptroller of any state or the Federal Government that you have violated any provisions of small loan
laws, banking or trust company laws, or credit union laws, or that you have violated any rule or regulation lawfully made by the Comptroller of
any state or the Federal Government?
Yes
No ______
i.
Had a lien or foreclosure action filed against you or any entity while you were associated with that entity?
Yes
No ______
If the response to any question above is answered “Yes”, please provide details including dates, locations, disposition, etc. Attach a copy of
the complaint and filed adjudication or settlement as appropriate.
FURTHER THE AFFIANT SAYETH NOT.
Biographical Affidavit – Supplement to AMC-02 (1301)
Page 3 of 4
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