SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As ofJanuary 1, 2015

DECLARANT:

ADDRESS:

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS

a. Real Properties

DESCRIPTIONKINDLOCATIONASSESSED VALUECURRENT FAIR MARKET VALUEACQUISITIONACQUISITION COST

(e.g. lot, house and lot, condominium, and improvements)(e.g., residential, commercial, industrial, agricultural and mixed used)YEARMODE

Subtotal: XXXX

b. Personal Properties

DESCRIPTIONYEAR ACQUIREDACQUISITION COST/AMOUNT

Cash in Bank2015 xxxxxx

Subtotal: -

TOTAL ASSETS (a+b):#VALUE!

2. LIABILITIES*

NATURENAME OF CREDITORSOUTSTANDING BALANCE

TOTAL LIABILITIES: -

NET WORTH: Total Assets less Total Liabilities =

I hereby certify that these are true and correct statements of my assets, liabilities, net worth.

Date:

(Signature of Declarant)

SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affiant exhibiting to me the above-stated government issued identification card.

(Person Administering Oath)