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99 � Q �� 5g <br /> EXHIBIT B-1 cont. <br /> For each source of income that your household receives,give the source of the income and the amount of income <br /> that can be expected from that source during the next 12 months. <br /> FAMILY MEMBER SOURCE/TYPE OF INCOME ANNUAL INCOME <br /> 4. List all checking and savings accounts(including IRS's,Keogh accounts and Certificates ofDeposit)ofall household <br /> members,including accounts disposed of during the past two years. <br /> FINANCIAL INSTITUTION ACCOUNT NO. BALANCE INTEREST RECEIVED <br /> 5. List the value of all stocks,bonds,trusts,pension contributions,or other assets: <br /> 6. Do you own a home or other real estate? <br /> 7. Did you have any assets in the last two years not listed above? If yes,did you dispose of any assets <br /> for less than fair market value? (This means that the assets were either given away or sold at less than the allotted <br /> market value.) What were the assets, the market value at the time of disposition, the amount received and the date you <br /> disposed of the assets? <br /> Annual Household Income: $ <br /> Add to Annual Household Income one of the following,(a),(b),or(c): <br /> (a)Actual Income from Asset(s)if total Asset(s)value is less than$5,000: $ <br /> OR, <br /> the greater of: <br /> (b)Actual Income from Asset(s)if total Asset(s)value is more than$5,000: $ <br /> (c)Imputed Income from Asset(s)if total Asset(s)value is more than$5,000 <br /> Asset(s)total S Rate of 2.0 %: $ <br /> Total Household Income: $ <br /> Note:Assets include items such as cash(wherever held),trust corpus,equity in real <br /> estate or capital investments, notes receivable, stocks, bonds, money market <br /> accounts, IRAs, retirement & pension funds, luxury personal items (gems, <br /> jewelry,art,coin collections,......),etc. <br /> Assets do not include necessary personal property such as clothing, furniture, <br /> 8-1-2 <br />