Name *

First Name

Last Name

Do you own or have an interest in stocks, bonds or interests in any businesses?

Yes

No

Not Sure

Do you own or have an interest in retirement or pension accounts even if you can not now get the funds? (IRA, ERISA,401(k), thrift savings accounts or profit or pension-sharing plans)

Yes

No

Not Sure

Do you own or have an interest in security deposits or prepaid accounts?

Yes

No

Not Sure

Do you own or have an interest in annuities, educational IRA.s, or trusts?

Yes

No

Not Sure

Do you own or have an interest in patents, copyrights, trademarks, licenses, or franchises?

Yes

No

Not Sure

Do you own or have an interest in an internet domain names or businesses (sole proprietorships, LLC, Joint venture, corporations ?

Yes

No

Not Sure

Are you entitled to any tax refunds?

Yes

No

Not Sure

Are you entitled to any support from anyone?

Yes

No

Not Sure

Does anyone owe you money for any reason?

Yes

No

Not Sure

Do you have a claim against anyone (even if you have not pursued it) for such things as automobile accidents, slip and fall accidents, employment discrimination claims or other claims of ANY nature?

IF YOU DO NOT DISCLOSE THESE SORTS OF CLAIMS YOU WILL LOOSE YOUR RIGHT TO PURSUE THEM!

Yes

No

Not Sure

Do you own or have an interest in life insurance policies?

Yes

No

Not Sure

Do you have an interest in any property due to someone having died (for instance, a living trust, life insurance, a will or inheritance or do you think you might be entitled to such property within the next 6 months?

Yes

No

Not Sure

Do you own or have an interest in any business assets?

Yes

No

Not Sure

Do you own or have an interest in any accounts receivables or commissions?

Yes

No

Not Sure

Do you own or have an interest in office equipment, office furnishings, machinery, fixtures or supplies used in business?

Yes

No

Not Sure

Do you own or have an interest in inventory, customer lists, mailing lists or any other business related property?

Yes

No

Not Sure

Do you own or have an interest in any farm or commercial fishing property?

Yes

No

Not Sure

Do you own or have an interest in any crops, farm or fishing supplies or any other farm or commercial fishing property?

Yes

No

Not Sure

Do you have possession of property belonging to someone else? I

Yes

No

Not sure

Do you have any stock options even if they cannot be exercised now?

No

Yes

Not sure