Statement of Financial Affairs1. Income from employment (wages/tips) or operation of business (commissions) (Including Severance Pay & Tax Refunds)Period2012 Year to date Income (h)Provide pay stubs for last 60 days$ AmountSection Break2012 Year to date Income (w)Provide pay stubs for last 60 days$ AmountSection Break2011 IncomeProvide copy tax return $ AmountSection Break2010 IncomeProvide copy tax return $ AmountSection Break2. Income other than from employment -- (ie unemployment/pension/social security/worker’s compensation & temporary disability)Period2012 Year to date Income (h)$ AmountSection Break2012 Year to date Income (w)$ AmountSection Break2011 IncomeProvide copy tax return$ AmountSection Break2010 IncomeProvide copy tax return$ AmountSection Break3. List all payments on loans, installment purchases of goods or services, and other debts, totaling more than $600 to any creditor made within the last 90 days.ListName and Address of Creditor and Relationship to YouDates of PaymentAmount PaidAmount Still Owed Add Remove4. Have you repaid any loans you made to a family member in the last year.ListName and Address of Family Member and Relationship to YouDates of PaymentAmount PaidAmount Still Owed Add Remove5. Law suits, executions, garnishments and attachmentsProvide copy of all lawsuits filed against you, or you have against others.Describe all property that has been garnished, seized, or attached under any legal or equitable process within the last year.Untitled NONE(Give us copies of pleadings or sheriff notices)ListName and Address of Person/Company for Whom the Property Was Seized (Creditor)Date of SeizureDescription and Value of Property Add Remove6. Repossessions, foreclosures, and returnsList all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within the last year. NONE(Provide Documents)ListName and Address of CreditorDate of Repossession, Foreclosure, Transfer or ReturnDescription and Value of Property7. GiftsList all gifts to family or friends or charitable contributions made within one year more than $200.00 to any person. NONEListName and Address of RecipientRelationship to You, if AnyDate of GiftDescription and Value of Gift8. LossesList all losses from fire, theft, gambling or other casualty within the last year. NONEListDescription and Value of PropertyDescription of Circumstances and Amount Covered by Insurance, if AnyDate of LossGambling losses - get records of winnings and losses from casino.9. Other transfers (including a gift or sale of something you owned that was worth more than $500.00)List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within the last two years. NONEListName and Address of Transferee and Relationship to YouDate of TransferDescription of Property Transferred and Value Received10. Closed financial accountsList all financial accounts (bank accounts) and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within the last year. NONEListName and Address of InstitutionType and Number of Account & Final BalanceAmount and Date of Sale or Closing11. Property held for another person - are you storing or holding anything that belongs to someone else.List all property that you hold or control that is owned by another person. NONEListName and Address of OwnerDescription and Value of PropertyLocation of Property12. Prior addressIf you have moved within the last two years, list all residences during the last two years, excluding your present address. NONEListAddressYour Name at the TimeDates of Occupancy13. List any business that you have had an ownership interest in in the last six (6) years. NONEListBusiness NameNature of BusinessBeginning & Ending Dates Add RemoveΔ