FEDERAL TRADE COMMISSION

FINANCIAL STATEMENT OF INDIVIDUAL DEFENDANT

Definitions and Instructions:

1. Complete all items. Enter “None” or “N/A” (“Not Applicable”) in the first field only of any item that does not apply to you. If you cannot fully answer a question, explain why.

2. “Dependents” include your spouse, live-in companion, dependent children, or any other person, whom you or your spouse (or your children’s other parent) claimed or could have claimed as a dependent for tax purposes at any time during the past five years.

3. “Assets” and “Liabilities” include ALL assets and liabilities, located within the United States or any foreign country or territory, whether held individually or jointly and whether held by you, your spouse, or your dependents, or held by others for the benefit of you, your spouse, or your dependents.

4. Attach continuation pages as needed. On the financial statement, state next to the Item number that the Item is being continued. On the continuation page(s), identify the Item number(s) being continued.

5. Type or print legibly. 6. Initial each page in the space provided in the lower right corner.

7. Sign and date the completed financial statement on the last page.

Penalty for False Information: Federal law provides that any person may be imprisoned for not more than five years, fined, or both, if such person:

(1) “in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or devise a material fact; makes any materially false, fictitious or fraudulent statement or representation; or makes or uses any false writing or document knowing the same to contain any materially false, fictitious or fraudulent statement or entry” (18 U.S.C. § 1001);

(2) “in any ... statement under penalty of perjury as permitted under section 1746 of title 28, United States Code, willfully subscribes as true any material matter which he does not believe to be true” (18 U.S.C. § 1621); or

(3) “in any (... Statement under penalty of perjury as permitted under section 1746 of title 28, United States Code) in any proceeding before or ancillary to any court or grand jury of the United States knowingly makes any false material declaration or makes or uses any other information . . . knowing the same to contain any false material declaration” (18 U.S.C. § 1623).

For a felony conviction under the provisions cited above, federal law provides that the fine may be not more than the greater of (i) $250,000 for an individual or $500,000 for a corporation, or (ii) if the felony results in pecuniary gain to any person or pecuniary loss to any person other than the defendant, the greater of twice the gross gain or twice the gross loss. 18 U.S.C. § 3571.

Federal Trade Commission Financial Statement of Individual Defendant

Case 4:14-cv-00815-BCW Document 9-1 Filed 09/18/14 Page 2 of 12

BACKGROUND INFORMATION

Full Name

Social Security No.

Current Address of Primary Residence

[Rent [Jown

From (Date):

(m ah

Driver’s License No.

State Issued

Phone Numbers Home: ( ) Fax: ( )

E-Mail Address

Date of Birth: / / (mm/dd/yyyy) Place of Birth

Internet Home Page

Previous Addresses for past five years (if required, use additional pages at end of form)

Address

From: i of Until: / / (mm/dd/yyyy) (mm/dd/yyyy)

[Rent [JOwn

From:

[Rent [Jown

From:

[Rent [Jown

Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they

were used:

Item 2. Information About Your Spouse or Live-In Companion

Spouse/Companion's Name

Social Security No.

Date of Birth / / (mm/dd/yyyy)

Address (if different from yours)

Phone Number

)

Place of Birth

( []Rent [Jown

From (Date): / / (mm/dd/yyyy)

Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they were used:

Employer's Name and Address

Job Title

Years in Present Job

Annual Gross Salary/Wages

ltem 3. Information About Your Previous Spouse

Name and Address

Social Security No.

Date of Birth / f (mm/dd/yyyy)

Item 4. Contact Information (name and address of closest living relative other than your spouse)

Name and Address

Phone Number

( )

Initials:

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 5. Information About Dependents (whether or not they reside with you

Name and Address Social Security No. Date of Birth / / (mm/dd/yyyy)

Relationship

Name and Address Social Security No. Date of Birth / os] (mm/dd/yyyy)

Relationship

Name and Address Social Security No. Ba of =

(mm/dd/yyyy)

Relationship

Social Security No. sab of fu

Name and Address

(mm/dd/yyyy)

Relationship

Item 6. Employment Information/Employment Income

Provide the following information for this year-to-date and for each of the previous five full years, for each business entity of which you were a director, officer, member, partner, employee (including self-employment), agent, owner, shareholder, contractor, participant or consultant at any time during that period. “Income” includes, but is not limited to, any salary, commissions, distributions, draws, consulting fees, loans, loan payments, dividends, royalties, and benefits for which you did not pay (e.g., health insurance premiums, automobile lease or loan payments) received by you or anyone else on your behalf.

Company Name and Address Dates Employed Income Received: Y-T-D & 5 Prior Yrs.

Year Income From (Month/Year) To (Month/Year) / / 20

Ownership Interest? [] Yes [] No Positions Held From (Month/Year) To (Month/Year)

Company Name and Address Dates Employed Income Received: Y-T-D & 5 Prior Yrs.

Year Income From (Month/Year) To (Month/Year)

/ / 20 Ownership Interest? [] Yes 1] No Positions Held From (Month/Year) To (Month/Year)

Company Name and Address Dates Employed Income Received: Y-T-D & 5 Prior Yrs.

Year Income From (Month/Year) To (Month/Year)

/ / 20 Ownership Interest? [] Yes (] No Positions Held From (Month/Year) To (Month/Year)

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Item 7. Pending Lawsuits Filed By or Against You or Your Spouse

List all pending lawsuits that have been filed by or against you or your spouse in any court or before an administrative agency in the United States or in any foreign country or territory. Note: At Item 12, list lawsuits that resulted in final judgments or settlements in your favor. At Item 21, list lawsuits that resulted in final judgments or settlements against you.

Caption of Proceeding

Item 8. Safe Deposit Boxes

List all safe deposit boxes, located within the United States or in any foreign country or territory, whether held individually or jointly and whether held by you, your spouse, or any of your dependents, or held by others for the benefit of you, your spouse, or any of your dependents.

Name of Owner(s

Court or Agency and Location Case No.

Name & Address of Depository Institution

Nature of Proceeding

Status or

Relief Requested Disposition

Contents

Initials:

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FINANCIAL INFORMATION

REMINDER: When an item asks for information regarding your “assets” and “liabilities” include ALL assets and liabilities, located within the United States or in any foreign country or territory, or institution, whether held individually or jointly, and whether held by you, your spouse, or any of your dependents, or held by others for the benefit of you, your spouse, or any of your dependents. In addition, provide all documents requested in Item 24 with your completed Financial Statement.

ASSETS

Item 9. Cash, Bank, and Money Market Accounts

List cash on hand (as opposed to cash in bank accounts or other financial accounts) and all bank accounts, money market accounts, or other financial accounts, including but not limited to checking accounts, savings accounts, and certificates of deposit. The term “cash on hand” includes but is not limited to cash in the form of currency, uncashed checks, and money orders.

a. Amount of Cash on Hand $ Form of Cash on Hand

b. Name on Account Name & Address of Financial Institution Account No. Current Balance

Item 10. Publicly Traded Securities List all publicly traded securities, including but not limited to, stocks, stock options, corporate bonds, mutual funds, U.S. government securities (including but not limited to treasury bills and treasury notes), and state and municipal bonds. Also list any U.S. savings bonds.

Owner of Security Issuer Type of Security No. of Units Owned

Broker House, Address Broker Account No.

Current Fair Market Value Loan(s) Against Security $ $

Owner of Security Issuer Type of Security No. of Units Owned

Broker House, Address Broker Account No.

Current Fair Market Value Loan(s) Against Security $ $

Owner of Security Issuer Type of Security No. of Units Owned

Broker House, Address Broker Account No.

Current Fair Market Value Loan(s) Against Security

$ $

Initials:

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Item 11. Non-Public Business and Financial Interests

List all non-public business and financial interests, including but not limited to any interest in a non-public corporation, subchapter-S corporation, limited liability corporation (“LLC”), general or limited partnership, joint venture, sole proprietorship, international business corporation or personal investment corporation, and oil or mineral lease.

Type of Business or Financial Owner ll If Officer, Director, Member Interest (e.g., LLC, partnership) (e.g., self, spouse) or Partner, Exact Title

Item 12. Amounts Owed to You, Your Spouse, or Your Dependents

Entity’s Name & Address

Debtor’s Name & Address

Date Obligation Incurred (Month/Year) /

Original Amount Owed

Current Amount Owed

Payment Schedule

Debtor’s Telephone

Debtor’s Name & Address

Debtor’s Relationship to You

Date Obligation Incurred (Month/Year) /

Original Amount Owed

Current Amount Owed

Payment Schedule

Debtor’s Telephone

Item 13. Life Insurance Policies

Debtor’s Relationship to You

List all life insurance policies (including endowment policies) with any cash surrender value.

Insurance Company’s Name, Address, & Telephone No.

Beneficiary

Nature of Obligation (if the result of a final court judgment or settlement, provide court name and docket number)

Policy No. Face Value

Insured

Beneficiary

Loans Against Policy | Surrender Value

$ $

Policy No. Face Value

Insured

Item 14. Deferred Income Arrangements List all deferred income arrangements, including but not limited to, deferred annuities, pensions plans, profit-sharing plans, 401(k) plans, IRAs, Keoghs, other retirement accounts, and college savings plans (e.g., 529 Plans).

Trustee or Administrator's Name, Address & Telephone No.

Name on Account

Loans Against Policy | Surrender Value

$ $

Account No.

Date Established Type of Plan

/ / (mm/dd/yyyy)

Name on Account

Surrender Value before Taxes and Penalties

ccount No.

Date Established Type of Plan

/ |

Surrender Value before Taxes and Penalties

Initials:

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Item 15. Pending Insurance Payments or Inheritances List any pending insurance payments or inheritances owed to you.

—— ee ss | ee eee $ / of

Registered Owner’s Name

Purchase Price

Original Loan Amount

Current Balance

Make

Vehicle Type

Registration State & No.

Address of Vehicle’s Location

Registered Owner’s Name

Account/Loan No.

Lender’s Name and Address

Purchase Price

Current Value

Original Loan Amount

Monthly Payment $

Current Balance

Make

Registration State & No.

Account/Loan No.

Current Value

Monthly Payment $

Model

Vehicle Type

Address of Vehicle’s Location

Registered Owner’s Name

Lender’s Name and Address

Purchase Price

Original Loan Amount

Current Balance

Make

Registration State & No.

Account/Loan No.

Current Value

Monthly Payment $

Model

Vehicle Type

Address of Vehicle’s Location

Registered Owner's Name

Lender’s Name and Address

Purchase Price

Original Loan Amount

Current Balance

Make

Registration State & No.

Account/Loan No.

Current Value

Monthly Payment $

Model

Address of Vehicle’s Location

Item 17. Other Personal Property List all other personal property not listed in Items 9-16 by category, whether held for personal use, investment or any other reason, including but not limited to coins, stamps, artwork, gemstones, jewelry, bullion, other collectibles, copyrights, patents, and other intellectual property.

Property Category (e.g., artwork, jewelry)

Name of Owner

Lender’s Name and Address

Property Location

Acquisition Cost

Current Value

Initials:

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Federal Trade Commission Financial Statement of Individual Defendant

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Item 18. Real Property List all real property interests (including any land contract)

Property’s Location Type of Property Name(s) on Title or Contract and Ownership Percentages

Acquisition Date (mm/dd/yyyy) Purchase Price Current Value Basis of Valuation

/ of $ $ Lender’s Name and Address Loan or Account No. Current Balance On First Mortgage or Contract

$ Monthly Payment

$ Other Mortgage Loan(s) (describe) Monthly Payment LC Rental Unit $

Current Balance Monthly Rent Received $ $

Property’s Location Type of Property Name(s) on Title or Contract and Ownership Percentages

Acquisition Date (mm/dd/yyyy) Purchase Price Current Value Basis of Valuation

/_/ $ $ Lender’s Name and Address Loan or Account No. Current Balance On First Mortgage or Contract

$ Monthly Payment

$ Other Mortgage Loan(s) (describe) Monthly Payment CJ Rental Unit $

Current Balance Monthly Rent Received

$ $ LIABILITIES

Item 19. Credit Cards List each credit card account held by you, your spouse, or your dependents, and any other credit cards that you, your spouse, or your dependents use, whether issued by a United States or foreign financial institution.

Name of Credit Card (e.g., Visa,

MasterCard, Department Store) Account No. Name(s) on Account Current Balance

Type of Tax Amount Owed Year Incurred

$ $ $

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Item 21. Other Amounts Owed by You, Your Spouse, or Your Dependents List all other amounts, not listed elsewhere in this financial statement, owed by you, your spouse, or your dependents.

Lender/Creditor's Name, Address, and Telephone No. | Nature of Debt (if the result of a court judgment or settlement, provide court name and docket number)

Lender/Creditor’s Relationship to You

a sa Was Incurred Original Amount Owed Current Amount Owed Payment Schedule

(mm/dd/yy) $ : Lender/Creditor's Name, Address, and Telephone No. | Nature of Debt (if the result of a court judgment or settlement, provide court name and docket number)

Lender/Creditor’s Relationship to You

Date Liability Was Incurred Original Amount Owed Current Amount Owed Payment Schedule

= (mm/dd/yyyy) $ $

OTHER FINANCIAL INFORMATION

Item 22. Trusts and Escrows

List all funds and other assets that are being held in trust or escrow by any person or entity for you, your spouse, or your dependents. Include any legal retainers being held on your behalf by legal counsel. Also list all funds or other assets that are being held in trust or escrow by you, your spouse, or your dependents, for any person or entity.

Date Established

Grantor Beneficiaries Present Market Value of Assets* (mm/dd/yyyy

Trustee or Escrow Agent’s Name & Address

“If the market value of any asset is unknown, describe the asset and state its cost, if you know it

Item 23. Transfers of Assets

List each person or entity to whom you have transferred, in the aggregate, more than $5,000 in funds or other assets during the previous five years by loan, gift, sale, or other transfer (exclude ordinary and necessary living and business expenses paid to unrelated third parties). For each such person or entity, state the total amount transferred during that period.

) / | $

Transfer Date Type of Transfer (mm/dd/yyyy) (e.g., Loan, Gift)

$ / $ / of $ / of

Transferee’s Name, Address, & Relationship Property Transferred Aggregate Value*

“If the market value of any asset is unknown, describe the asset and state its cost, if you know it

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Item 24. Document Requests Provide copies of the following documents with your completed Financial Statement.

Federal tax returns filed during the last three years by or on behalf of you, your spouse, or your dependents.

All applications for bank loans or other extensions of credit (other than credit cards) that you, your spouse, or your dependents have submitted within the last two years, including by obtaining copies from lenders if necessary.

Item 9 For each bank account listed in Item 9, all account statements for the past 3 years.

For each business entity listed in Item 11, provide (including by causing to be generated from accounting records) the Item 11 most recent balance sheet, tax return, annual income statement, the most recent year-to-date income statement, and all general ledger files from account records.

All appraisals that have been prepared for any property listed in Item 17, including appraisals done for insurance Item 17 purposes. You may exclude any category of property where the total appraised value of all property in that category is less than $2,000.

Item 18 All appraisals that have been prepared for real property listed in Item 18.

Item 21 Documentation for all debts listed in Item 21.

All executed documents for any trust or escrow listed in Item 22. Also provide any appraisals, including insurance appraisals that have been done for any assets held by any such trust or in any such escrow.

SUMMARY FINANCIAL SCHEDULES

Assets Liabilities

Item 22

Cash on Hand (Item 9) Loans Against Publicly Traded Securities (Item 10) Funds Held in Financial Institutions (Item 9) Vehicles - Liens (Item 16)

U.S. Government Securities (Item 10) Real Property — Encumbrances (Item 18)

Publicly Traded Securities (Item 10) Credit Cards (Item 19)

Non-Public Business and Financial Interests (Item 11) Taxes Payable (Item 20)

Amounts Owed to You (Item 12) Amounts Owed by You (Item 21)

Life Insurance Policies (Item 13) Other Liabilities (itemize)

Deferred Income Arrangements (Item 14) Vehicles (Item 16)

Other Personal Property (Item 17)

Real Property (Item 18)

Other Assets (Itemize)

$ Total Assets | $ Total Liabilities $

Item 26. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents Provide the current monthly income and expenses for you, your spouse, and your dependents. Do not include credit card payments separately; rather, include credit card expenditures in the appropriate categories.

PAPA 1H | [1H

Income (State source of each item) Expenses Salary - After Taxes Mortgage or Rental Payments for Residence(s) Source: Fees, Commissions, and Royalties Property Taxes for Residence(s) Source: Interest Rental Property Expenses, Including Mortgage Payments, Taxes, Source: and Insurance Dividends and Capital Gains Car or Other Vehicle Lease or Loan Payments Source: Gross Rental Income Food Expenses Source: Profits from Sole Proprietorships Clothing Expenses Source: Distributions from Partnerships, S-Corporations, Utilities and LLCs Source: Initials: 9 of 10 Federal Trade Commission Financial Statement of Individual Defendant

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Item 26. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents (cont.)

Distributions from Trusts and Estates Medical Expenses, Including Insurance Source: $ Distributions from Deferred Income Arrangements Other Insurance Premiums Source: Social Security Payments Other Transportation Expenses Alimony/Child Support Received Other Expenses (Itemize)

Gambling Income

Other Income (Itemize)

Total Income | $ Total Expenses

ATTACHMENTS

Item 27. Documents Attached to this Financial Statement List all documents that are being submitted with this financial statement. For any Item 24 documents that are not attached, explain why.

Item No. Document Relates To Description of Document

| am submitting this financial statement with the understanding that it may affect action by the Federal Trade Commission or a federal court. | have used my best efforts to obtain the information requested in this statement. The responses | have provided to the items above are true and contain all the requested facts and information of which | have notice or knowledge. | have provided all requested documents in my custody, possession, or control. | Know of the penalties for false statements under 18 U.S.C. § 1001, 18 U.S.C. § 1621, and 18 U.S.C. § 1623 (five years imprisonment and/or fines). | certify under penalty of perjury under the laws of the United States that the foregoing is true and correct.

Executed on:

(Date) Signature

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