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Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must beidentified as a part of this statement and signed). <br />Number of Shares Name of Securities C . Market Value <br />Date of Total Value <br />Quotation/Exchange Quotation/Exchange <br />Section 4. Real Estate Owned. <br />Type of Property <br />Address <br />Date Purchased <br />Original Cost <br />Present Market Value <br />Name & <br />Address of Mortgage Holder <br />Mortgage Account Number <br />Mortgage Balance <br />Amount of Payment per Month/Year <br />Status of Mortgage <br />(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 <br />Property B <br />4% t <br />1411 lt',Xielcut& 0r <br />leietc.0,G( 34.4ggz <br />a��GOI <br />KS, LX)O — <br />5a. - <br />emus €- nit <br />o. i3x 11°44 8'7 I <br />Lt�lalSlritlY ky r-102410 <br />tos-g 53.383:'; <br />600 - <br />Soo•It) <br />6u.Asei t Ji,e,C <br />iA� PlercgiPt 3ugb-z_ <br />t , Loot3 <br />(S, 500 - <br />00-k sbb - <br />-e' <br />Property C <br />fit` <br />t��QTet`CErc( 31(.441_ <br />Q' a0b- <br />l5) COD <br />' <br />3Ca— <br />Section S Other Personal Property and Other Assets. <br />(Describe, and if any is pledged as security, stater name and: address of lien holder, amount of lien, terms <br />of payment and if delinquent,_ describe; elinauencoL <br />Gsaa ger 2 5, Ooo <br />t500u- <br />atet- s tOOdo- W°:en:It GOC. - <br />lc 1 e 'I'S I 1pUo- <br />c r ' -a Co D— <br />I A. 600— <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 />c\.) Ave__ <br />Section 7. Other Liabilities. (Describe in detail.) <br />p P2¢Li% 04t4 S \ %- 00o — <br />7 <br />Doo — <br />a sof.— <br />Section 8. Life insurance Held. (Give face amount and cash surrender value of policies name of insurance company and beneficiaries) <br />L:N;A.N1+-1, t)a 1--• it s5 as, tXw— <br />I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above <br />and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining <br />a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General <br />(Reference 18 U.S.C. 1001). <br />Signature: <br />Date: 3 3 0 10 Social Security Number: <br />oZ(o,l,,, <br />Signature: <br />PLEASE NOTE: <br />Date: Zr p-)6 Social Security Number: <br />The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or comments <br />concerning this estimate or any other aspect of this information, please contact Chief, Administrative Branch; U.S. Small Business <br />Administration, Washington, D.C. 20416, and Clearance Officer, Paper Reduction Project (3245-0188), Office of Management and Budget, <br />Washington, D.C.20503. PLEASE DO NOT SEND FORMS TO OMB. <br />tiYiu F. <br />tz-�., ;� MY COMMr • • ?N # DD 630775 <br />EXPIPT.: ivary23 2011 <br />1,?,f, !h `` sondyd r.:.. i,:u .:ry Pao Underwriters } `_ <br />