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j argPization schedule, may be requeste <br />5. YES . ❑ NO ❑ Do you hold any personal property as an investment (i.e., coin <br />collection or antique car)? DO NOT include necessary personal items <br />such as a car or furniture. <br />If yes,"please explain: <br />Value: S <br />6. YES ❑ NO ❑ Do you have a safe deposit box? <br />7. YES ❑ NO ❑ Are any assets held jointly with a person who does not reside with <br />you? <br />Which assets? <br />Held with whom? <br />What portion of the assets do you have access to? <br />8. YES ❑ NO ❑ Have you received any LUMP SUM payments in the last 24 months? If <br />yes, please indicate amount and explain: <br />. S <br />9. YES ❑ NO ❑ In the past two years, have you disposed of any assets for less than <br />Fair Market Value? <br />Market Value Less Cash Received $ <br />If yes, please explain <br />10. Enter Total Assets (A) from Box B, preceding page. $ <br />11. Total the amounts from questions 3 through 11. <br />TOTAL ASSETS $ <br />E. PERSONAL REFERENCE (Excluding family members) <br />Name <br />Address <br />Phone No. <br />F. VEHICLE/DRIVER I.D. <br />1. Driver's License # State Issued <br />Car Make Color + Year _ Lic. # <br />d-o%m r.A K" w%rsr-%A a,• O. , I 1 f3 f o%m4WAo%A M iklin A,n n/,nF•s,%4r G <br />