Form Crs-13f-2.0 - Financial Statement Of Debtor Page 4
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4OTHER ASSETS
☐ Yes
☐ No
Do you or your spouse/companion own U. S. Savings Bonds?
Value: $
☐ Yes
☐ No
Do you own stocks or other types of bonds?
If yes, list details below
Name of Issuer
Address of Issuer
Value
$
$
List automobiles owned or being purchased by you, your spouse/companion or dependent:
Model/Year
Make/License Number
Value
$
$
$
$
List other assets by Type:
Value: $
Antiques, art collection
Value: $
Camper/Recreational Vehicle
Value: $
Jewelry valued over $5,000
Value: $
Boat, Motorcycle, or Motorbike
☐ Yes
☐ No
Is any of the property listed above owned jointly with anyone else?
If yes, with whom:
H. ITEMS WHICH MIGHT AFFECT FUTURE ASSETS:
☐ Yes
☐ No
Are you involved in a lawsuit in which you might receive money or something of value:
If yes, state where the suit is filed and what it involves (include Court number and caption):
☐ Yes
☐ No
Are you a Trustee, Executor, or Administrator of an estate?
If yes, give details:
☐ Yes
☐ No
If anyone holding money on your behalf?
If yes, give specific details:
☐ Yes
☐ No
If there any likelihood you will receive an inheritance?
If yes, give specific details:
☐ Yes
☐ No
Have you sold or transferred either real property or stocks and bonds in the past three years?
If yes, give specific details:
Are your wages and/or those of your spouse/companion under garnishment at this time? ☐ Yes
☐ No
If yes, give specific details:
☐ Yes
☐ No
Are there any outstanding unpaid judgments against you for debts other than this one?
If yes, give specific details and attach copies of the bills.
☐ Yes
☐ No
Do you owe large medical bills?
If yes, give specific details and attach copies of the bills.
With knowledge of the penalties for false statements provided by 18 United State Code 1001 ($10,000 fine
and/or five years imprisonment) and with knowledge that this financial statement is submitted by me to affect
action by the U. S. Department of Treasury, I certify that I believe the above statement is true and that it is a
complete statement of all my income and assets, real and personal, whether held in my name or by any other.
Date:
Signature:
Date:
Signature:
Please Note: If you have added additional sheets to this form, or added information on the back of this page
or any page, please also sign those pages.
CRS-13F-2.0, CRS Financial Statement Form - Individual
Page 4 of 4
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