Financial Statement Of Debtor (Submitted For Government Action On Claims Due The United States) Page 6

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65. I have submitted a financial Statement to the following within the last three years: **
Name
Address
Phone Number
Contact
With knowledge of the penalties for false statements provided by 18 United States Code 1001 ($10,000 fine and/or five years’ imprisonment)
and with the knowledge that this financial statement is submitted by me to affect action by the U.S. Department of Justice, 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
** If you have submitted a financial statement to anyone or any entity within the past three years, please sign below to indicate you agree to
have that person or entities release a copy of the financial statement to the U.S. Attorney’s Office.
**** If you have added additional sheets to this form or added information on the back of this page, you must also sign these sheets.
* $
PLEASE INDICATE THE AMOUNT YOU PROPOSE TO PAY EACH MONTH. **
-- – - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
RELEASE OF FINANCIAL INFORMATION
I AGREE TO HAVE ANY LENDER, INCLUDING BUT NOT LIMITED TO ALL BANKS, FINANCIAL
INSTITUTIONS, CREDIT CARD COMPANIES, AND/OR RENTAL AGENCIES, RELEASE TO THE UNITED
STATES ATTORNEY'S OFFICE FOR THE NORTHERN DISTRICT OF GEORGIA COPIES OF ANY AND ALL
FINANCIAL STATEMENTS I HAVE GIVEN THEM WITHIN THE PAST THREE YEARS.
Signature
Date
6

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