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0, CITY OF MIAMI
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IN COMPLIANCE WITH CITY OF MIAMI CODE SEC. 2 6
- 19)
DESCRIPTION VALUE Please list below the name and address of every person,
whether individual or corporation, to whom you owe a
US Century Bank 152,757.
77 liability exceeding $5,000, and the total amount of
Savings Account indebtedness. "Liability" is defined as any monetary debt
or obligation owed by you to another person, including
1671 SW 32 Place 184,640.
00 credit card retail installment accounts; taxes owed;
Miami, FL 33145 indebtedness on a life insurance policy owed to the
issuing company; or accrued income taxes on net
120 SW 37th Ave, Apt 506 68,
00980. unrealized appreciation.
Miami, FL 33134
Name A
/ ddress of Creditors: Amount Owed:
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approximately $15,
00000.
Note: You are not limited to the space on the lines in this form. Attach additional if necessary.
sheet(s)
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 DJ - AFFIDAVIT
The information disclosed herein and on any attachments hereto is true and correct to my knowledge.
State of Florida
County of
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Name of person signing and his/her title (public officer, trustee or personal representative)
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PUBLIC
Personally known to me, or JOT
o OFFICE:
C4EAL`
Produced identification:
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