Financial Statement Of Debtor (Submitted For Government Action On Claims Due The United States) Page 4

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49. CASH
Provide Name and address of Bank or Institution
Amount in Account or
Name and Address of Bank
FILL IN THE ACCOUNT NUMBER
on Deposit
or Financial Institution
Checking Account Number
$
Savings Account(s) Number
$
Credit Union Account(s) Number
$
Money Market Account
$
Certificates of Deposit
$
IRA or Keogh Account
$
Total Amount
$-----------------------------
OTHER ASSETS
50. Do you or your spouse/companion own U.S. Savings Bonds?
Yes
No
If yes, number (
) State Denomination
Value
$------------------------------
51. Do you own stocks or other type bonds?
Yes
No
If yes, list value and name and address of the issuer:
$------------------------------
(If additional space needed use back of last page )
52. Do you receive any other cash compensation such as: an insurance annuity,
lottery winnings, pensions, or disability benefits?
Yes
No
Do you receive food stamps, SSI funds or unemployment compensation?
Yes
No
If yes to either of these questions list below the source and amount:
$------------------------------
$-------------------------------
(If additional space needed use back of last page)
53. List make and model of any auto owned or being purchased by you, your spouse/companion or dependent:
Model/Year
Make/License No.
Value
Total Amount
$--------------------------------------
Do you or your spouse/companion own:
Value
a. boat?
$----------------
a. camper recreational vehicle
$---------------
a motorcycle/bike
$---------------
Antiques, art objects or stamp collections
$---------------
Jewelry valued more than $5000.00.
$---------------
Total Amount
$--------------------------------------
Is any of the property listed above owned jointly with anyone else?
Yes
No
If yes, Whom:
4

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