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32 <br />Confidential <br />Section 3. Stock and Bonds <br />Number of <br />Shares <br />Name of Securities <br />Cost <br />Market Value <br />Quotation/Exchange <br />Date of <br />Quotation/Exchange <br />Total Value <br />Section 4. Real Estate (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part <br />of this statement and signed. <br />Property A Property B Property C <br />Type of Property <br />Address <br />Date Purchased <br />Original Cost <br />Present Market Value <br />Name 8� <br />Address of Mortgage Holder <br />Mortgage Account Number <br />Mortgage Balance <br />Amount of Payment per Month/Year <br />Status of Mortgage <br />Section S. Other Personal Property (Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, <br />terms of payment and if delinquent, describe delinquency). <br />Section 6. Unpaid Taxes Describe in detail, as to.type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches). <br />Section 7. Other Liabilities Describe in detail. <br />Section S. Life Insurance field Give face amount and cash surrender value of policies — name of insurance company and beneficiaries. <br />I authorize OCSBLP /Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify <br />the above and the statements contained in the attachments are true and accurate as of the statement date(s). These statements are made for the purpose <br />of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. <br />Attorney General (Reference 18 U.S.C. 1001). <br />Signature: Date: Social Security Number: <br />Signature: Date: Social Security Number: <br />