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201109462 <br /> A Checking Account? � <br /> Certificates of Deposit? � <br /> Money Market Account? $ <br /> A Safety Deposit Box? � <br /> Money Held in Trust? $ <br /> Any Stocks,Bonds or Securities? � <br /> Any Treasury Bills? � <br /> A Retirement Fund?(Includes IRA's,Keogh accounts) $ <br /> Annuities? $ <br /> A Pension Fund? � <br /> Have any Personal Property held as an Investment(this includes:paintings,artwork, <br /> collectors or show cars,je�velry,coin or stamp collections,antiques etc.)? $ <br /> Other equity in real estate,rental property,land contracts/contract for deeds or other real <br /> estate holding or other capital investments(this includes your personal residence,mobile <br /> homes,vacant land,farms,vacation homes,or commercial property)? Market Value Less: <br /> (a)any unpaid balance on loans secured by property,and(b)reasonable costs that would <br /> be incurred in selling the asset—penalties,broker fees,etc. $ <br /> Received any Lump Sum Receipts? When $ <br /> (Include inheritances,capital gains,lottery winnings,insurance settlements and other claims) <br /> Other Assets not listed? $ <br /> Have you disposed of any assets(e.g.real estate,cash,stock,etc.)in the past two years? <br /> If yes,please describe: $ <br /> 5. EMPLOYMENT HISTORY: <br /> A licant Em lo ed B : <br /> How Lon : Su ervisor: <br /> Current Wa e:$ Hours er week: Overtime wa e:$ Overtime hours er week: <br /> Em lo er Address• <br /> S ouse Em lo ed B : <br /> How Lon : Su ervisor: <br /> Current Wa e:$ Hours er week: Overtime wa e:$ Overtime hours er week: <br /> Em lo er Address: <br /> Other A licant Em lo ed B : <br /> How Lon : Su ervisor: <br /> Current Wa e:$ Hours er week: Overtime wa e:$ Overtime hours er week: <br /> Em lo er Address: <br />