Form Cms-379 - Financial Statement Of Debtor Page 3
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425. Real Estate Owned
Address
How Owned (jointly,
Date
Cost
Unpaid Amount
individually, etc.)
Acquired
of Mortgage
26. Real Estate Being Purchased Under Contract
Address
Name of Seller
Contract Price
Principal Amount Still Owing Next Cash Payment Due (date)
Amount (of next payment due)
27. Life Insurance Policies
Company
Face Amount
Cash Surrender Value
Outstanding Loans
28. All Real and Personal Property Owned by Spouse and Dependents Valued in Excess of $200 (List each item separately)
29. All Transfers of Property Including Cash (by loan, gift, sale, etc.) That You Have Made Within the Last 3 Years (items of $300 or over)
Date
Amount
Property Transferred
To Whom
30. Are you a party in any lawsuit now pending?
Yes, give details below
No
31. Are you a trustee, executor, or administrator?
Yes, give details below
No
32. Is anyone holding any moneys on your behalf?
Yes, give details below
No
Form CMS-379 (07/07) EF 07/2007
Page 3 of 4
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Parent category: Medical