Form Ftb 3861a C1 - Bank And Corporation - Statement Of Financial Condition And Other Information Page 5
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812.
Securities (Bonds, stocks, etc.)
Amount of
Name of Company
Number of
Cost
Fair Market
Indebtedness
Date Pledged
Units
Value
if Pledged
a.
$
$
$
$
b.
c.
d.
e.
f.
g.
h.
i. Total
$
$
$
$
13.
Judgments
a.
Amount of Judgment
Date Recorded
Where Recorded
b.
$
c.
d.
e. Total
$
14.
Affidavit
Under penalties of perjury, I declare that I have examined the information given in this statement and, to the best of my knowledge and belief, it is
true, correct, and complete, and I further declare that there are no assets, owned either directly or indirectly, or income of any nature other than as
shown in this statement.
a. Date of this statement
b. Signature
c. Title
FTB 3861A C1 (REV 11-94) PAGE 5
PAGE 11
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