Federal Trade Commission et al v. Dalbey et al, No. 1:2011cv01396 - Document 283 (D. Colo. 2013)
Court Description: Amended Stipulated ORDER for Final Judgment and Order for Permanent Injunction and Other Equitable Relief as to Russell T. Dalbey and Catherine L. Dalbey re: 280 Joint MOTION for Judgment. By Judge R. Brooke Jackson on 07/22/13. (Attachments: # 1 Attachment A, # 2 Attachment B) (alvsl)
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Federal Trade Commission et al v. Dalbey et al Doc. 283 Att. 1 BACKGROUND INFORMATION Item 1. Information About You Full Name Social Security No. Current Address of Primary Residence Driver’s License No. State Issued Phone Numbers ) Home: ( Fax: ( ) Rent Own From (Date): Internet Home Page Date of Birth: / / (mm/dd/yyyy) Place of Birth E-Mail Address / / (mm/dd/yyyy) Previous Addresses since January 1, 2006 (if required, use additional pages at end of form) Address From: / / (mm/dd/yyyy) Rent Address From: Own / Rent Address From: Rent Until: / / (mm/dd/yyyy) / Until: / / Until: / / Own / / Own Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they were used: Item 2. Information About Your Spouse or Live-In Companion Spouse/Companion's Name Social Security No. Address (if different from yours) Phone Number ( Date of Birth / / (mm/dd/yyyy) Place of Birth ) Rent Own From (Date): / / (mm/dd/yyyy) Identify any other name(s) and/or social security number(s) you have used, and the time period(s) during which they were used: Job Title Employer’s Name and Address Years in Present Job Annual Gross Salary/Wages $ Item 3. Information About Your Previous Spouse Name and Address Social Security No. Date of Birth / / (mm/dd/yyyy) Item 4. Contact Information (name and address of closest living relative other than your spouse) Phone Number Name and Address ( ) Initials: 1 of 10 Federal Trade Commission Financial Statement of Individual Defendant Dockets.Justia.com Item 5. Information About Dependents (whether or not they reside with you) Social Security No. Name and Address Date of Birth / / (mm/dd/yyyy) Relationship Name and Address Date of Birth / / (mm/dd/yyyy) Social Security No. Relationship Name and Address Date of Birth / / (mm/dd/yyyy) Social Security No. Relationship Name and Address Date of Birth / / (mm/dd/yyyy) Social Security No. Relationship Item 6. Employment Information/Employment Income Provide the following information for this year-to-date and for each full year since January 1, 2006, for each business entity of which you were a director, officer, member, partner, employee (including self-employment), agent, owner, shareholder, contractor, participant or consultant at any time during that period. “Income” includes, but is not limited to, any salary, commissions, distributions, draws, consulting fees, loans, loan payments, dividends, royalties, and benefits for which you did not pay (e.g., health insurance premiums, automobile lease or loan payments) received by you or anyone else on your behalf. Company Name and Address Dates Employed Income Received: This year to date From (Month/Year) / Ownership Interest? From (Month/Year) / Yes To (Month/Year) / Year Income 20 $ $ To (Month/Year) / No Positions Held $ $ / / $ / / $ Company Name and Address Dates Employed Income Received: This year to date From (Month/Year) / Ownership Interest? From (Month/Year) / Yes To (Month/Year) / Year Income 20 $ $ To (Month/Year) / No Positions Held $ $ / / $ / / $ Company Name and Address Dates Employed Income Received: This year to date Year From (Month/Year) / Ownership Interest? Positions Held Yes To (Month/Year) / From (Month/Year) / To (Month/Year) / No Income 20 $ $ $ $ / / $ / / $ Initials: 2 of 10 Federal Trade Commission Financial Statement of Individual Defendant Item 7. Pending Lawsuits Filed By or Against You or Your Spouse List all pending lawsuits that have been filed by or against you or your spouse in any court or before an administrative agency in the United States or in any foreign country or territory. Note: At Item 12, list lawsuits that resulted in final judgments or settlements in your favor. At Item 21, list lawsuits that resulted in final judgments or settlements against you. Nature of Status or Caption of Proceeding Court or Agency and Location Case No. Relief Requested Proceeding Disposition Item 8. Safe Deposit Boxes List all safe deposit boxes, located within the United States or in any foreign country or territory, whether held individually or jointly and whether held by you, your spouse, or any of your dependents, or held by others for the benefit of you, your spouse, or any of your dependents. Name of Owner(s) Name & Address of Depository Institution Box No. Contents Initials: 3 of 10 Federal Trade Commission Financial Statement of Individual Defendant FINANCIAL INFORMATION REMINDER: When an item asks for information regarding your “assets” and “liabilities” include ALL assets and liabilities, located within the United States or in any foreign country or territory, or institution, whether held individually or jointly, and whether held by you, your spouse, or any of your dependents, or held by others for the benefit of you, your spouse, or any of your dependents. In addition, provide all documents requested in Item 24 with your completed Financial Statement. ASSETS Item 9. Cash, Bank, and Money Market Accounts List cash on hand (as opposed to cash in bank accounts or other financial accounts) and all bank accounts, money market accounts, or other financial accounts, including but not limited to checking accounts, savings accounts, and certificates of deposit. The term “cash on hand” includes but is not limited to cash in the form of currency, uncashed checks, and money orders. a. Amount of Cash on Hand $ b. Name on Account Form of Cash on Hand Name & Address of Financial Institution Account No. Current Balance $ $ $ $ $ Item 10. Publicly Traded Securities List all publicly traded securities, including but not limited to, stocks, stock options, corporate bonds, mutual funds, U.S. government securities (including but not limited to treasury bills and treasury notes), and state and municipal bonds. Also list any U.S. savings bonds. Owner of Security Issuer Broker House, Address Broker Account No. Current Fair Market Value $ Owner of Security Issuer Broker House, Address Type of Security No. of Units Owned Loan(s) Against Security $ Broker Account No. Current Fair Market Value $ Owner of Security Issuer Broker House, Address Type of Security No. of Units Owned Loan(s) Against Security $ Broker Account No. Current Fair Market Value $ Type of Security No. of Units Owned Loan(s) Against Security $ Initials: 4 of 10 Federal Trade Commission Financial Statement of Individual Defendant Item 11. Non-Public Business and Financial Interests List all non-public business and financial interests, including but not limited to any interest in a non-public corporation, subchapter-S corporation, limited liability corporation (“LLC”), general or limited partnership, joint venture, sole proprietorship, international business corporation or personal investment corporation, and oil or mineral lease. Entity’s Name & Address Type of Business or Financial Interest (e.g., LLC, partnership) Owner (e.g., self, spouse) Ownership % If Officer, Director, Member or Partner, Exact Title Item 12. Amounts Owed to You, Your Spouse, or Your Dependents Debtor’s Name & Address Date Obligation Incurred (Month/Year) / Current Amount Owed $ Original Amount Owed $ Payment Schedule $ Debtor’s Telephone Debtor’s Relationship to You Debtor’s Name & Address Date Obligation Incurred (Month/Year) / Current Amount Owed $ Nature of Obligation (if the result of a final court judgment or settlement, provide court name and docket number) Debtor’s Telephone Original Amount Owed $ Payment Schedule $ Nature of Obligation (if the result of a final court judgment or settlement, provide court name and docket number) Debtor’s Relationship to You Item 13. Life Insurance Policies List all life insurance policies (including endowment policies) with any cash surrender value. Policy No. Loans Against Policy $ Beneficiary Policy No. Insured Insurance Company’s Name, Address, & Telephone No. Beneficiary Insured Insurance Company’s Name, Address, & Telephone No. Loans Against Policy $ Face Value $ Surrender Value $ Face Value $ Surrender Value $ Item 14. Deferred Income Arrangements List all deferred income arrangements, including but not limited to, deferred annuities, pensions plans, profit-sharing plans, 401(k) plans, IRAs, Keoghs, other retirement accounts, and college savings plans (e.g., 529 Plans). Name on Account Trustee or Administrator’s Name, Address & Telephone No. Date Established / / (mm/dd/yyyy) Account No. Type of Plan Surrender Value before Taxes and Penalties $ Account No. Type of Plan Surrender Value before Taxes and Penalties $ Name on Account Trustee or Administrator’s Name, Address & Telephone No. Date Established / / Initials: 5 of 10 Federal Trade Commission Financial Statement of Individual Defendant Item 15. Pending Insurance Payments or Inheritances List any pending insurance payments or inheritances owed to you. Type Amount Expected Date Expected (mm/dd/yyyy) $ / / $ / / $ / / Item 16. Vehicles List all cars, trucks, motorcycles, boats, airplanes, and other vehicles. Vehicle Type Registered Owner’s Name Make Registration State & No. Purchase Price $ Account/Loan No. Model Address of Vehicle’s Location Lender’s Name and Address Registered Owner’s Name Make Registration State & No. Purchase Price $ Account/Loan No. Model Address of Vehicle’s Location Lender’s Name and Address Registered Owner’s Name Vehicle Type Vehicle Type Year Year Year Make Registration State & No. Purchase Price $ Account/Loan No. Model Address of Vehicle’s Location Lender’s Name and Address Registered Owner’s Name Make Registration State & No. Purchase Price $ Account/Loan No. Model Address of Vehicle’s Location Lender’s Name and Address Vehicle Type Year Original Loan Amount $ Current Value $ Current Balance $ Monthly Payment $ Original Loan Amount $ Current Value $ Current Balance $ Monthly Payment $ Original Loan Amount $ Current Value $ Current Balance $ Monthly Payment $ Original Loan Amount $ Current Value $ Current Balance $ Monthly Payment $ Item 17. Other Personal Property List all other personal property not listed in Items 9-16 by category, whether held for personal use, investment or any other reason, including but not limited to coins, stamps, artwork, gemstones, jewelry, bullion, other collectibles, copyrights, patents, and other intellectual property. Property Category (e.g., artwork, jewelry) Name of Owner Property Location Acquisition Cost Current Value $ $ $ $ $ $ Initials: 6 of 10 Federal Trade Commission Financial Statement of Individual Defendant Item 18. Real Property List all real property interests (including any land contract) Type of Property Property’s Location Acquisition Date (mm/dd/yyyy) / / Lender’s Name and Address Purchase Price $ Name(s) on Title or Contract and Ownership Percentages Current Value $ Loan or Account No. Other Mortgage Loan(s) (describe) Acquisition Date (mm/dd/yyyy) / / Lender’s Name and Address Purchase Price $ Current Balance On First Mortgage or Contract $ Monthly Payment $ Rental Unit Monthly Payment $ Monthly Rent Received Current Balance $ $ Name(s) on Title or Contract and Ownership Percentages Type of Property Property’s Location Basis of Valuation Current Value $ Loan or Account No. Basis of Valuation Current Balance On First Mortgage or Contract $ Monthly Payment $ Rental Unit Monthly Payment $ Current Balance $ Other Mortgage Loan(s) (describe) Monthly Rent Received $ LIABILITIES Item 19. Credit Cards List each credit card account held by you, your spouse, or your dependents, and any other credit cards that you, your spouse, or your dependents use, whether issued by a United States or foreign financial institution. Name of Credit Card (e.g., Visa, MasterCard, Department Store) Account No. Name(s) on Account Current Balance $ $ $ $ $ Item 20. Taxes Payable List all taxes, such as income taxes or real estate taxes, owed by you, your spouse, or your dependents. Type of Tax Amount Owed Year Incurred $ $ $ Initials: 7 of 10 Federal Trade Commission Financial Statement of Individual Defendant Item 21. Other Amounts Owed by You, Your Spouse, or Your Dependents List all other amounts, not listed elsewhere in this financial statement, owed by you, your spouse, or your dependents. Lender/Creditor’s Name, Address, and Telephone No. Nature of Debt (if the result of a court judgment or settlement, provide court name and docket number) Lender/Creditor’s Relationship to You Date Liability Was Incurred Original Amount Owed Current Amount Owed Payment Schedule / / $ $ (mm/dd/yyyy) Lender/Creditor’s Name, Address, and Telephone No. Nature of Debt (if the result of a court judgment or settlement, provide court name and docket number) Lender/Creditor’s Relationship to You Date Liability Was Incurred / / (mm/dd/yyyy) Original Amount Owed $ Current Amount Owed $ Payment Schedule OTHER FINANCIAL INFORMATION Item 22. Trusts and Escrows List all funds and other assets that are being held in trust or escrow by any person or entity for you, your spouse, or your dependents. Include any legal retainers being held on your behalf by legal counsel. Also list all funds or other assets that are being held in trust or escrow by you, your spouse, or your dependents, for any person or entity. Trustee or Escrow Agent’s Name & Address Date Established (mm/dd/yyyy) / / Grantor Beneficiaries Present Market Value of Assets* $ / / $ / / $ *If the market value of any asset is unknown, describe the asset and state its cost, if you know it. Item 23. Transfers of Assets List each person or entity to whom you have transferred, in the aggregate, more than $5,000 in funds or other assets since January 1, 2006, by loan, gift, sale, or other transfer (exclude ordinary and necessary living and business expenses paid to unrelated third parties). For each such person or entity, state the total amount transferred during that period. Transfer Date (mm/dd/yyyy) / / $ / / $ Property Transferred Aggregate Value* $ Transferee’s Name, Address, & Relationship / Type of Transfer (e.g., Loan, Gift) / *If the market value of any asset is unknown, describe the asset and state its cost, if you know it. Initials: 8 of 10 Federal Trade Commission Financial Statement of Individual Defendant Item 24. Document Requests Provide copies of the following documents with your completed Financial Statement. Federal tax returns filed since January 1, 2006, by or on behalf of you, your spouse, or your dependents. All applications for bank loans or other extensions of credit (other than credit cards) that you, your spouse, or your dependents have submitted since January 1, 2006, including by obtaining copies from lenders if necessary. Item 9 For each bank account listed in Item 9, all account statements since January 1, 2006. Item 11 For each business entity listed in Item 11, provide (including by causing to be generated from accounting records) the most recent balance sheet, tax return, annual income statement, the most recent year-to-date income statement, and all general ledger files from account records. Item 17 All appraisals that have been prepared for any property listed in Item 17, including appraisals done for insurance purposes. You may exclude any category of property where the total appraised value of all property in that category is less than $2,000. Item 18 All appraisals that have been prepared for real property listed in Item 18. Item 21 Documentation for all debts listed in Item 21. Item 24 All executed documents for any trust or escrow listed in Item 22. Also provide any appraisals, including insurance appraisals that have been done for any assets held by any such trust or in any such escrow. SUMMARY FINANCIAL SCHEDULES Item 25. Combined Balance Sheet for You, Your Spouse, and Your Dependents Assets Liabilities Cash on Hand (Item 9) $ Loans Against Publicly Traded Securities (Item 10) $ Funds Held in Financial Institutions (Item 9) $ Vehicles - Liens (Item 16) $ U.S. Government Securities (Item 10) $ Real Property – Encumbrances (Item 18) $ Publicly Traded Securities (Item 10) $ Credit Cards (Item 19) $ Non-Public Business and Financial Interests (Item 11) $ Taxes Payable (Item 20) $ Amounts Owed to You (Item 12) $ Amounts Owed by You (Item 21) $ Life Insurance Policies (Item 13) $ Other Liabilities (Itemize) Deferred Income Arrangements (Item 14) $ $ Vehicles (Item 16) $ $ Other Personal Property (Item 17) $ $ Real Property (Item 18) $ $ Other Assets (Itemize) $ $ $ $ $ $ Total Assets $ $ Total Liabilities $ Item 26. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents Provide the current monthly income and expenses for you, your spouse, and your dependents. Do not include credit card payments separately; rather, include credit card expenditures in the appropriate categories. Income (State source of each item) Salary - After Taxes Source: Fees, Commissions, and Royalties Source: Interest Source: Dividends and Capital Gains Source: Gross Rental Income Source: Profits from Sole Proprietorships Source: Distributions from Partnerships, S-Corporations, and LLCs Source: $ $ $ $ $ $ Expenses Mortgage or Rental Payments for Residence(s) Property Taxes for Residence(s) Rental Property Expenses, Including Mortgage Payments, Taxes, and Insurance Car or Other Vehicle Lease or Loan Payments Food Expenses Clothing Expenses $ $ $ $ $ $ Utilities $ $ Initials: 9 of 10 Federal Trade Commission Financial Statement of Individual Defendant Item 27. Combined Current Monthly Income and Expenses for You, Your Spouse, and Your Dependents (cont.) Distributions from Trusts and Estates Source: Distributions from Deferred Income Arrangements Source: Social Security Payments $ $ Medical Expenses, Including Insurance Other Insurance Premiums Gambling Income $ $ Alimony/Child Support Received Other Transportation Expenses $ $ Other Expenses (Itemize) $ $ $ Other Income (Itemize) $ $ $ $ Total Income $ $ $ $ Total Expenses $ ATTACHMENTS Item 28. Documents Attached to this Financial Statement List all documents that are being submitted with this financial statement. Item No. Document Relates To Description of Document I am submitting this financial statement with the understanding that it may affect action by the Federal Trade Commission or a federal court. I have used my best efforts to obtain the information requested in this statement. The responses I have provided to the items above are true and contain all the requested facts and information of which I have notice or knowledge. I have provided all requested documents in my custody, possession, or control. I know of the penalties for false statements under 18 U.S.C. § 1001, 18 U.S.C. § 1621, and 18 U.S.C. § 1623 (five years imprisonment and/or fines). I certify under penalty of perjury under the laws of the United States that the foregoing is true and correct. Executed on: _______________ (Date) ___________________________________ Signature 10 of 10 Federal Trade Commission Financial Statement of Individual Defendant
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