Financial Disclosure Affidavit Form (Page 4 of 8) in pdf

Financial Disclosure Affidavit Form Page 4

Attachment 4

D. Stocks, Bonds, and Investments

Do you have any of the following? (Check all that apply)

stock in a corporation or other entity

bonds

mutual funds

a retirement account

Yes. Attach documentation showing the value of each.

No.

(Go to E)

E. Real Property

Do you own any of the following? (Check all that apply)

home

land

rental property

Yes. Attach a copy of the latest appraisal or other documentation attesting to the value of your real property.

No.

(Go to F)

F. Personal Property

Do you own a motor vehicle, motorcycle, or other recreational vehicle?

Yes. Attach a copy of the title(s) or registration document(s).

(Go to Step 6)

Step 6: OTHER SOURCES OF INCOME

A. Lawsuits

1. Are you a party to a lawsuit which may result in the transfer of income or assets to you, or to another

party?

Yes. (Go to 2)

No. (Go to B)

2. Has the lawsuit settled?

Yes. Attach documentation showing the settlement date and terms of the settlement which transfer income

or assets to you or from you to another party.

No.

(Go to 3)

3. What is the name, address, and telephone number of the attorney representing you?

_____________________________________________________________________________________

(Go to B)

B. Insurance Settlements

1. Are you currently receiving, or will you be receiving, proceeds from an insurance settlement?

Yes. Attach documentation showing the settlement date, claim number, and amount. (Go to 2)

No. (Go to C)

Financial Disclosure Affidavit Form Page 4