STATE OF ) ) ss: COUNTY OF ) AFFIDAVIT OF FINANCIAL CONDITION, being duly sworn, deposes and says: A. I am over the age of 21 years and reside at:. B. I make this affidavit (the Affidavit ) at the request of ( Bank ) for the purpose of informing Bank of my present financial condition. C. I have personal knowledge of the facts stated in this Affidavit and such facts are true, accurate and complete in all material respects. I understand that Bank will rely upon the accuracy and truth of the statements and representations made by me. Based on the facts and circumstances surrounding the negotiations pursuant to which this Affidavit is made, Bank s full and complete reliance on the statements and representations made herein is reasonable. D. I hereby represent to Bank that the financial statement and supporting schedules (the Financial Statement ) described on Exhibit A and attached hereto as a part of Exhibit A is the most recent Financial Statement prepared for or by me. The Financial Statement is true, correct, and complete in all respects, and fairly and accurately presents my financial condition as of the date set forth therein. E. Since the date of the Financial Statement mentioned in paragraph D to the date of this Affidavit, I hereby represent to Bank that there have been no material changes in the financial condition of myself except as specifically identified and set forth herein.
1. In the preceding twelve (12) months, I have not received Income from any source whatsoever, except: Type of Income Amount Date of Receipt Source Salary and Wages: Bonuses and Awards: Fees and Commissions: Interest: Dividends: Other Income (describe):
2. As of the date of this Affidavit, I do not receive any Income and am not entitled to receive any Income from any source whatsoever, except: Date of Type of Income Amount Recipient Receipt Source Salary and Wages: Bonuses and Awards: Fees and Commissions: Interest: Dividends: Other Income (describe):
3. I am not entitled to receive any compensation, profits, profit sharing, pension or retirement fund distributions of any kind, except: Source Amount There are no agreements or other understandings relating to the above Income except as listed on Exhibit C; true, accurate and complete copies of which are attached hereto as a part of Exhibit C.
4. As of the date of this Affidavit, I do not have any agreements or understandings that will entitle me to receive future Income from any source whatsoever, except: Anticipated Type of Income Amount Date of Receipt Source Salary and Wages: Bonuses and Awards: Fees and Commissions: Interest: Dividends: Other Income (describe):
5. Other than as set out in the Financial Statement (attached hereto as Exhibit A), I do not own or control any Assets in the United States or in any other country or territory, except: (a) Deposit accounts: Depository Account Account Type of Account (Address) Name Number Balance Checking Acct(s): Savings Acct(s): Money Market Acct(s): IRA(s): CD(s): Other (describe): True, accurate and complete copies of the most current statements of the above accounts are attached hereto as Exhibit D.
(b) Brokerage, Commodities and other Investment Accounts: Broker Account Account Market Type of Account (Address) Name Number Balance Brokerage: Commodities: Other (describe): True, accurate and complete copies of the most current statements of the above accounts are attached hereto as Exhibit E. (c) Investment Securities and Commodities: Type of Date Market Investment Custodian Acquired Value Stock(s): Bond(s): Mutual Funds:
Commercial Paper: Commodities: Options: Letters of Credit: Warrants: Other (describe): (d) Money orders, checks, cashier s checks, traveler s checks, drafts, negotiable instruments, prepaid expenses or retainer funds or escrow funds, except: Date Owner Description Custodian Acquired Amount
(e) Corporations, Partnerships, Joint Ventures, Associations, Business Trusts, and Other Business Investments and Interests: Name of Business Description of Interest Value Contemporaneously with the delivery of this Affidavit, I am submitting Affidavits of Financial Condition to Bank for each business in which I have an ownership interest greater than one percent (1%), except for those which have stock or other evidence of ownership which is traded publicly. (f) Interests in real estate whether residential, commercial or otherwise (including but not limited to fee simple ownership, leases, life estates, remainder interests, easements options to purchase, contracts of sale, development rights, oil, gas, mineral or other rights): Description of Date Mortgages Address Property Acquired Cost (if any)
(g) Automobiles, Airplanes, Boats, Trailers, Trucks and Other Vehicles: Serial Date Description Number Acquired Cost Liens (h) Promissory Notes, Mortgages, Lease Payments, Contracts Receivable, Accounts Receivable, and other Receivables: Description Amount per item: (i) Jewelry and Art with a value having an individual value in excess of $500.00 Date Market Description Acquired Cost Value
(j) Patents, Inventions, Tradenames, Trademarks, Service marks, Copyrights, Royalty Agreements, License and Franchise Agreements: Description Value (k) Equipment and Inventory: Description Value (l) Other Assets: Date Market Description Acquired Cost Value
6. Except for the accounts listed in numbers 5(a) and (b) above, in the preceding twelve (12) months I have not had a right of withdrawal or deposit in any checking account, savings account, certificate of deposit, deposit account or other account or fund of money, brokerage, commodities, or other investment account in the United States or in any other country or territory, except: Depository or Previous Current Institution Type of Account Account Account (Address) Account Name Number Name Balance
7. I do not lease, or have access to, any safes, vaults, safe deposit boxes, or depositories, except: Depository or Institution Account Account (Address) Name Number Contents
8. I have not removed any property from any safe, vault, safe deposit box or depository during the last (12) twelve months, except: Depository or Institution Property Date Reason for Current (Address) Removed Removed Removal Custodian
9. Except as set out in the Financial Statement (attached hereto as Exhibit A) or as disclosed in this Affidavit, I do not have any right, title or interest in any Assets in the United States or in any other country or territory, except: Description Description of Authority Beneficial Asset of Assets or Interest Owners Value
10. Except as set out in the Financial Statement (attached hereto as Exhibit A) or as disclosed in this Affidavit, I am not the beneficiary under any insurance policies or annuities, except: Insured Beneficiary Owner Insurer Policy Number Type of Policy Face Amount of Policy Cash Value Annual Premium Annual Dividends Paid Policy 1 Policy 2 Policy 3 Policy 4 (If more than 4 policies, attach additional schedules)
11. Except as set out in the Financial Statement (attached hereto as Exhibit A) or as disclosed in this Affidavit, I am not a beneficiary under any will, estate, trust, or foundation, except: Description Entity of Interest Trustee Amount
12. Except as set out in the Financial Statement (attached hereto as Exhibit A) or as disclosed in this Affidavit, I do not have any claim against any insurance company, person, estate, trust, association, joint venture, partnership, corporation, or other entity, except: Individual Amount of or Entity Description of Claim Claim
13. Other than as set out in the Financial Statement (attached hereto as Exhibit A) or as disclosed in this Affidavit, I do not own or control any Assets in the United States or any other country or territory having an individual value in excess of $500, except: Description of Asset Date Acquired Cost Market Value The total aggregate value of all Assets having an individual value of $500 or less and not set out in the Financial Statement (attached hereto as Exhibit A) or in this Affidavit is approximately $.
14. My fixed monthly expenses and other expenses that occur on a regular basis are as follows: Description of Expense Person or Entity Paid Amount
15. Other than as identified in number 12 above, I am not a plaintiff, defendant, or otherwise involved in any arbitration, judicial, administrative or other legal or quasi-legal proceeding, except: Description Forum or Matter or Amount in Matter of Case Court Case Number Controversy
16. Except as set out in the Financial Statement (attached hereto as Exhibit A) or as disclosed in this Affidavit, I do not have an ownership interest in any judgment against a third party, except: Name of Case Court Case Number Amount of Judgment
17. Except as set out in the Financial Statement (attached hereto as Exhibit A) or as disclosed in this Affidavit, I am not entitled to receive money from any federal, state, county, or municipal government, or from any agency or department thereof (including, without limitation, any tax refunds or other reimbursements of any kind), except: Description Governmental Entity Amount
18. Other than as set out in the Financial Statement (attached hereto as Exhibit A), I do not have any Liabilities in the United States or in any other country or territory, except: (a) Debts (including without limitation, debts to banks, savings and loans, finance companies or other entities or individuals): Holder (Address) Unpaid Balance Account Number Collateral (b) Guaranties, Purchase Agreements and Endorsements: Beneficiary or Holder Principal Debtor Amount Collateral (c) Pledges and Assignments: Beneficiary or Holder Amount Collateral
(d) Judgments, Orders or Decrees: Description Holder Amount (e) Delinquent Taxes and Tax Liens (including, but not limited to, income, franchise, property, withholding, FICA, or sales taxes): Taxing Authority Description of Taxes or Lien (f) Other Obligations and Liabilities whether present, future, contingent, conditional or otherwise: Description Amount Collateral
19. Neither my Assets, nor I am, to my knowledge, subject to any investigation or inquiry by any federal, state, county, municipal, or other governmental department, agency or authority under any laws, regulations or requirements (including, without limitation, those relating to the environment, taxation, employment matters, drug enforcement and other criminal matters), except: Description Date Name of Authority Status
20. I have not made any gifts having a value greater than $500.00 within the last twelve (12) months, except: Date of Acquisition Market Recipient Description Gift Cost Value The total aggregate value of all such gifts of $500 or less over the last twelve (12) months is approximately $.
21. Other than as set out in number 20 above, I have not transferred or conveyed any Assets within the last twelve (12) months other than for fair market value, except: Date of Acquisition Market Transferee Description Transfer Value Value
22. During the past twelve (12) months, I have not made any payments to my trade creditors, outside of the ordinary course of business, except: Creditor Date Reason Amount
23. Other than as listed in question 22 above, I have not made any payments exceeding $2,000.00 to any person, entity or trust during the last twelve months, except: Recipient Date Reason Amount
24. During the past twelve (12) months, other than as listed in numbers 22 and 23 above, I have not made any payments to any of my creditors, except (i) payments to creditors whose claims were fully secured at the time of payment by valid and perfected security interests in assets having a value at least as great as the amount of the indebtedness owed to the creditor; and (ii) the following: Balance Recipient Date Reason Amount (if any)
25. The tax returns attached hereto as Exhibit F are true, accurate and complete copies of the tax returns, schedules, and any amendments, which I filed, jointly or separately, with the Internal Revenue Service for the last two (2) tax years.
26. During the past seven (7) years, I have not filed for or been subject to a receivership, a bankruptcy or similar proceeding under any receivership, bankruptcy or other debtor relief laws, except: Type of Bankruptcy Ownership Date of Entity or other proceeding Interest Proceeding
27. If Exhibit G is completed and attached hereto, I understand that, contemporaneous with the delivery of this Affidavit Bank is entering into certain agreements with the undersigned as itemized on Exhibit F, which agreements are incorporated herein by reference (and collectively called the Transaction ). In such event, I understand and agree that, this Affidavit (and any other affidavit(s) submitted in connection with the Transaction) is a material inducement to the Bank to enter into the Transaction and that Bank would not enter into the Transaction in the absence of this Affidavit and such other affidavit(s). It is acknowledged and agreed that in the event that a material misrepresentation or omission is contained in this Affidavit or in one of such other affidavits, at the option of the Bank after discovery thereof, my liability to Bank with respect to the unpaid amount of the indebtedness which is the subject matter of the Transaction shall be reinstated and any releases of liability executed by the Bank as part of the Transaction shall become null and void from their inception but without in any manner affecting the validity and enforceability of any releases executed in favor of Bank as part of the Transaction. I acknowledge that in addition to the foregoing, I will be liable to Bank for the damages occasioned by my misrepresentation or omission all as specifically set forth in the Transaction. For purposes hereof, a misrepresentation or omission (either alone or in conjunction with other misrepresentations or omissions) is to understate Assets by an amount in excess of $10,000.00. This Affidavit of Financial Condition is executed under my hand and seal. Affiant s Signature Print Name This Affidavit of Financial Condition was sworn to and subscribed before me by this day of, 2010. (OFFICIAL SEAL) Official Signature of Notary, Notary Public Notary s printed or typed name My commission expires:
EXHIBIT A Financial Statement Date of Statement Preparer Recipient A true, accurate and complete copy of the Financial Statement (including all schedules) is attached hereto.
EXHIBIT B Deferred Income Agreements Name of Source Agreement Amount True, accurate and complete copies of all such financial statements are attached hereto.
EXHIBIT C Deposit Account Statements True, accurate and complete copies of the most current statements of the deposit accounts listed in 5(a) are attached hereto.
EXHIBIT D Investment Account Statements True, accurate and complete copies of the most current statements of the investment accounts listed in 5(b) are attached hereto.
EXHIBIT E Tax Returns True, accurate and complete copies of all tax returns (including all schedules and any amendments) filed for the last three (3) tax years are attached hereto.
EXHIBIT F List of Settlement/Restructure Documents Settlement Agreement and Mutual Release