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DESCRIPTION VALUE Please list below the name and address of every person,
whether individual or corporation, to whom you owe a
Primary Home Approximate
liability exceeding $5,000, and the total amount of
1671 SW 32nd Place 185,237
indebtedness. "Liability" is defined as any monetary debt
Investment Property Approximate or obligation owed by you to another person, including
120 SW 37th AVE, Apt 506 91, 970 credit card retail installment accounts; taxes owed;
indebtedness on a life insurance policy owed to the
Savings Account Approximate
issuing company; or accrued income taxes on net
147, 592.87
unrealized appreciation.
2,
87
486.
JP Morgan Chase Bank N.
A. $00
360,000.
Tampa, FL 33634
11060
Note: You are not limited to the space on the lines in this form. Attach additional sheet(s)
if necessary.
Page 1 of 2
PART C] -NETWORTH
Net worth is the difference between total assets and total liabilities, not merely those listed in PART A (Above),which have
a value in excess of $5,000. Please enter your net worth as of December 31 of the tax year or a more recent date.
PART D] -AFFIDAVIT
The information disclosed herein and on any attachments hereto is true and correct to my knowledge.
o /
Ardlia
Si ature of the Per..
n Reporting Date
State of Florida
County of DR)
i,
Sworn to (or affirmed) and subscribed before me on this the 1/
4.)(-'
day of J —
20 f
by:
Fral1Cs Ji,,
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Name of person signing and his her
/ title (public officer, trustee or personal representative)
NOTARY PUBLIC
Personally known to me, or
SEAL OF OFFICE:
Produced identification:
TOOO B.
HANNON
Type of Identification Produced) 1 Honda
ss " ''% Notary Public -State
Tres Augo 22. 2014
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V; My, m
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iss on #
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Page 2 of 2