Form De 9406 - Combined Statement Of Financial Condition And Income And Expense Declaration Page 5

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K. Other Assets
If you have any Life Interest or Remainder Interest, either vested or contingent, in any trust or estate, or are a beneficiary of any trust, complete the
following information, and furnish a copy of the instrument creating the trust or estate.
Name of Trust or Estate
Present Value of Trust
Value of Your Interest
Annual Income
$
$
$
$
$
$
$
$
$
If you are the grantor or donor for any trust, or the trustee or fiduciary for any trust, complete the following information, and furnish a copy of the
instrument creating the trust.
Name of Corpus or Trust
Value
$
$
$
If you have any other assets, or interests in assets, actual or contingent, other than those listed herein, describe fully:
If any foreclosure proceedings are pending at present on any real estate which you own or in which you have an interest, enter description and
location of such real estate.
Was the State of California named as a party to the court filings?
No
Yes
If yes, please furnish a copy of the court filings.
DECLARATION
I declare, under penalty of perjury, that the foregoing instruments are true and complete to the best of my knowledge and belief.
Signed on
at
California.
(Date)
(City)
(County)
(Signature)
DE 9406 Rev. 3 (2-11) (INTERNET)
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