Form De 9406 - Combined Statement Of Financial Condition And Income And Expense Declaration Page 4
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5F. Description of Motor Vehicles, Airplanes, or Boats (Include License, Vessel, or Tail Nmber.)
Fair Market Value
Balance Due
$
$
TOTAL VALUE ------------------------------------------------------------------------------------------------------------------------
$
$
G. Securities, Stocks, Bonds, and Savings Bonds
Number of Units
Fair Market Value
Balance Due
$
$
Name of Stockbroker
Address
H. Description of Furniture and Fixtures, Machinery and Equipment
Fair Market Value
Balance Due
Furniture (Household) -----------------------------------------------------------------------------------------------------------
$
$
Furniture /Fixtures (Business) -------------------------------------------------------------------------------------------------
Machinery---------------------------------------------------------------------------------------------------------------------------
Equipment (Other than motor vehicles)-------------------------------------------------------------------------------------
Miscellaneous----------------------------------------------------------------------------------------------------------------------
TOTAL VALUE -------------------------------------------------------------------------------------------------------------------
$
$
I. Life Insurance Policies Now in Effect
Right to Change
Name of Company
Policy Number
Policy Amount
Cash Surrender Value
Balance Due on Loan
Beneficiary (Y or N)
$
$
$
$
$
$
$
$
$
$
$
$
J. Accounts or Notes Receivable (Furnish a copy of the instrument creating the Accounts or Notes Receivable.)
Name
Address
Phone Number
Fair Market Value
Balance Due
$
$
$
$
$
$
$
$
$
$
DE 9406 Rev. 3 (2-11) (INTERNET)
Page 4 of 5
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