SB566,58,14 Print Name Here: ....

SB566,58,15 Residence Address: ....

SB566,58,16 Schedule “A"

SB566,58,17 Financial Disclosure

SB566,58,21 The following general categories of assets and liabilities are not all inclusive and if other assets or liabilities exist they should be listed. Assets should be listed according to which spouse has title (including assets owned by a spouse or the spouses with one or more third parties) and at their approximate market value.

SB566,58,22 Husband   Wife   Spouse (Name)   Spouse (Name)   Both Names

SB566,58,23 I.   Assets:

SB566,58,24 A.   Real estate (gross value)

SB566,58,25 B.   Stocks, bonds and mutual funds

SB566,59,2 C.   Accounts at and certificates and other instruments issued by financial institutions

SB566,59,4 D.   Mortgages, land contracts, promissory notes and cash

SB566,59,5 E.   Partnership interests

SB566,59,6 EL.   Limited liability company interests

SB566,59,7 F.   Trust interests

SB566,59,8 G.   Livestock, farm products, crops

SB566,59,9 H.   Automobiles and other vehicles

SB566,59,10 I.   Jewelry and personal effects

SB566,59,11 J.   Household furnishings

SB566,59,12 K.   Life insurance and annuities:

SB566,59,13 1.   Face value

SB566,59,14 2.   Cash surrender value

SB566,59,15 L.   Retirement benefits (include value):

SB566,59,16 1.   Pension plans

SB566,59,17 2.   Profit sharing plans

SB566,59,18 3.   HR-10 KEOGH plans

SB566,59,19 4.   IRAs

SB566,59,20 5.   Deferred compensation plans

SB566,59,21 M.   Other assets not listed elsewhere

SB566,59,22 II.   Obligations (total outstanding balance):