-CRZ United States of America v. Frederick, No. 4:2008cv03226 - Document 10 (D. Neb. 2010)
Court Description: ORDER granting 7 Motion for supplementary proceedings. The defendant, Mark A. Frederick, shall appear before the undersigned in Courtroom 2, 593 Federal Building, 100 Centennial Mall North, Lincoln, Nebraska 68508 on January 27, 2011 at 1:00 p.m. to participate in a debtor's examination. Ordered by Magistrate Judge Cheryl R. Zwart. (CRZ)
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-CRZ United States of America v. Frederick Doc. 10 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEBRASKA UNITED STATES OF AMERICA, Plaintiff, v. MARK A. FREDERICK, Defendant. ) ) ) ) ) ) ) ) ) 4:08CV3226 MEMORANDUM AND ORDER IT IS ORDERED: 1) The government’s motion for supplementary proceedings, (filing no. 7), is granted; and a. b. 2) The defendant, Mark A. Frederick, shall appear before the undersigned in Courtroom 2, 593 Federal Building, 100 Centennial Mall North, Lincoln, Nebraska 68508 on January 27, 2011 at 1:00 p.m. to participate in a debtor’s examination. At the debtor’s examination, Mark Frederick will be required to answer questions concerning his/her assets, income. The defendant, Mark A. Frederick, shall complete and sign the attached financial statement and shall bring the completed financial statement, and all items listed on Attachment A, to the debtor’s examination on January 27, 2011. The clerk shall serve a copy of this order on the defendant, Mark Frederick. DATED this 14th day of December, 2010. BY THE COURT: s/ Cheryl R. Zwart United States Magistrate Judge Dockets.Justia.com U.S. Department of Justice Financial Statement of Debtor (Submitted for Government Action on Claims Due the United States) NOTE: Use additional sheets where space on this form is insufficient or continue on back of last page. FINANCIAL STATEMENT OF DEBTOR Authority for the solicitation of the requested information is one or more of the following: 5 U.S.C. 301, 901 (see Note, Executive Order 6166, June 10, 1933); 28 U.S.C. 501, et seq.; 31 U.S.C. 951, et seq.; 44 CFR 3101; 4 CFR 101, et seq.; 28 CFR 0.160, 0.171 and Appendix to Subpart Y. Fed R.Civ.P. 33(a), 28 U.S.C. 1651, 3201 et seq. The principal purpose for gathering this information is to evaluate your ability to pay the Government claim or judgment against you. Routine uses of the information are established in the following U.S. Department of Justice Case File Systems published in Vol. 42 of the Federal Register: Justice/CIV-001 at page 53321; Justice/TAX-001 at page 15347; Justice/USA-00 at pages 53408-53410, Justice/CRIM-016 at page 12774. If the requested information is not furnished, the U.S. Department of Justice has the right to such disclosure of the information by legal methods. Section 1 Personal Information 1. Full Name(s) _______________________________ _______________________________ Street Address: _______________________________ City ____________________ State ______ Zip _______ 1a. Home Telephone: ( ) ___________________ 1b. Cellular Number: ( )___________________ 2. Marital Status: ~ Married ~ Separated ~ Not Married (single, divorced, widowed) County of Residence: __________ How long at this address? _____________ 2a. Spouse’s Name ___________________________ 3. Your Social Security Number ___________________ 2b. Spouse’s Date of Birth________________ 4. Your Date of Birth __________________ 5. ~ Own Home ~ Rent ~ Other (specify, i.e. share rent, live with relative) _____________________________ ___________________________________________________________________________________________ 6. List the dependants you can claim on your tax return First Name Relationship Age Does this person live with you? ____________________ _____________ ______ ~ Yes ~ No ____________________ _____________ ______ ~ Yes ~ No ____________________ _____________ ______ ~ Yes ~ No Section 2 Employment Information 7. Your employer ______________________________ Street Address _________________________________ City ____________________ State ______ Zip _______ W ork telephone No. ( ) _____________________ 7a. How long with this employer? __________________ 7b. Occupation (title)____________________________ 8. Spouse’s employer ____________________________ Street Address __________________________________ City ____________________ State ______ Zip _______ W ork telephone No. ( ) _______________________ 8a. How long with this employer? __________________ 8b. Occupation (title) ____________________________ Ú Ú Ú Ú Ú ATTACHM ENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 3 months from each employer (i.e. pay stubs, earning statements). Section 3 Your Business Information 9. Are you or your spouse self-employed or operate a business? (Check “Yes” if either applies) ~ Yes ~ No If yes, provide the following information: 9a. Name of Business ______________________________ 9c. Employer Identification No._________________ 9b. Street Address _________________________________ City _______________________ State ____________ Zip _____________ Telephone ( )_______________ Ú Ú Ú Ú Ú ATTACHM ENTS REQUIRED: Please provide proof of self-employment income for the prior 3 months (i.e. invoices, commissions, tax returns, sales records, income statement) Name_____________________________ SSN_____________________ Page 2 Section 4 10. Do you receive income from sources other than your employer and/or own business (Check all that apply) Other Income Information ~ Pension ~ Social Security ~ Other (specify, i.e. child support, alimony, rental property) ________________________________________________________ Ú Ú Ú Ú Ú ATTACHM ENTS REQUIRED: Please provide proof of pension/social security/other income for the past 3 months from each payor, including any statements showing deductions. Section 5 Banking, Investment, Cash, Credit and Life Ins. Information 11. CHECKING ACCOUNTS. List all checking accounts 11a. Type of Account Checking Full name of Bank, Credit Current Account Union or Institution Bank Account No. Balance Name_________________________ ________________ $_____________ Address _______________________ City _____________________ State _________ Zip__________ 11b. Checking 12a. Type of Account ___________ Full name of Bank, Credit Current Account Union or Institution Bank Account No. Balance Name_________________________ ________________ $_____________ Address _______________________ City _____________________ State _________ Zip__________ 12b. ___________ Name_________________________ ________________ $_____________ Address _______________________ City _____________________ State _________ Zip__________ Name_________________________ ________________ $_____________ Address _______________________ City _____________________ State _________ Zip__________ ____________________________________________________________________________________________ 12. OTHER ACCOUNTS. List all other accounts including savings, brokerage and money market, not listed in 11. Ú Ú Ú Ú Ú ATTACHM ENTS REQUIRED. Please include your current bank/financial statements for the past 3 months for all accounts. ____________________________________________________________________________________________ 13. INVESTM ENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of deposits and retirement assets such as IRAs, Keogh and 401(k) plans. Name of Company Number of Shares Current Value 13a. ___________________________ ______________ $_____________ 13b. ___________________________ ______________ $_____________ 13c. ___________________________ ______________ $_____________ ____________________________________________________________________________________________ 14. CASH ON HAND. Include any money that you have that is not in the bank. 14a. Total Cash on Hand $_________________ ____________________________________________________________________________________________ 15. CREDIT DEBT. List all lines of credit, including credit cards and signature loans. (Attach a separate sheet if you need more space.) 15a. Full name of Credit Institution Credit Limit Current Balance Name_________________________ $___________ $____________ Address _______________________ City _____________________ State _________ Zip__________ Minimum Monthly Payment $________________ Name_____________________________ Section 5 (continued) SSN_____________________ 15b. Full name of Credit Institution Credit Limit Current Balance Name_________________________ $___________ $____________ Address _______________________ City _____________________ State _________ Zip__________ Page 3 Minimum Monthly Payment $________________ 15c. Full name of Credit Institution Credit Limit Current Balance Minimum Monthly Payment Name_________________________ $___________ $____________ $________________ Address _______________________ City _____________________ State _________ Zip__________ ____________________________________________________________________________________________ 16. LIFE INSURANCE. Do you have life insurance with a cash value? ~ Yes ~ No (Term Life Insurance does not have a cash value) 16a. Name of Insurance Company ________________________________________________ 16b. Policy Number(s) _________________________________________________________ 16c. Owner of Policy __________________________________________________________ 16d. Current Cash Value $_____________________ 16e. Outstanding Loan Balance (if applicable) $__________________________ Section 6 Other 17. OTHER INFORM ATION. Respond to the following questions related to your financial condition: (Attach a separate sheet if you need more space.) 17a. Do you have a safe deposit box? ~ Yes ~ No If yes, please include the name and address of location of box, the box number and the contents below: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 17b. Do you have a will? ~ Yes ~ No; if yes, where is it kept? _______________________________________ 17c. Are there any garnishments against your wages ~ Yes ~ No If yes, who is the creditor?________________ _________________________________ Date of Judgment ______________ Amount of Debt $_____________ 17d. Are there any judgments against you? ~ Yes ~ No If yes, who is the creditor/plaintiff?________________ _________________________________ Date of Judgment ______________ Amount of Debt $_____________ 17e. Are you a party to a lawsuit? ~ Yes ~ No If yes, amount of suit $_______________ Possible completion date ________________ Court ___________________________________________________ Subject of suit ________________________________________________________________________________ 17f. Have you ever filed bankruptcy? ~ Yes ~ No If yes, date filed _______________________ Date discharged _________________________ 17g. In the past 10 years have you transferred any assets out of your name for less than their actual value? ~ Yes ~ No If yes, what asset(s)? __________________________ Value of asset at time of transfer $_________ W hen was it transferred? ________________ To whom was it transferred? ________________________________ 17h. Do you anticipate any increase in household income in the next 2 years? ~ Yes ~ No If yes, why will the income increase? _________________________________ How much will it increase? _______ 17i. Are you a beneficiary of a trust or an estate? ~ Yes ~ No If yes, name of trust/estate?________________ If yes, anticipated amount to be received? $_______________ W hen will amount be received? _________________ 17j. Are you a participant in a profit sharing plan? ~ Yes ~ No If yes, name of plan?_______________________________________________ Value of plan $ ________________ Name_____________________________ Section 7 Assets and Liabilities * Current Value is the amount you could sell the asset for today SSN_____________________ Page 4 18. PURCHASED AUTOM OBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (if you need additional space, attach a separate sheet.) Description *Current Current Loan (year, make, model) Value Balance 18a. _______________________ $_______ $__________ ___________________________ Name of Purchase Lender Date ____________________ __________ ____________________ Monthly Payments $________ 18b. _______________________ $_______ $__________ ____________________ __________ ___________________________ ____________________ $________ 19. LEASED AUTOM OBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (if you need additional space, attach a separate sheet.) Description Current Lease Name of Lease Monthly (year, make, model) Balance Lender Date Payments 19a. _________________________ $__________ ____________________ __________ $________ _____________________________ ____________________ 19b. _________________________ _____________________________ $__________ ____________________ __________ ____________________ $________ Ú Ú Ú Ú Ú ATTACHM ENTS REQUIRED. Please include your current statement from lender with monthly vehicle payment and current balance of the loan for each vehicle purchased or leased. ____________________________________________________________________________________________ 20. REAL ESTATE. List all real estate you own. (If you need additional space, attach a separate sheet.) Lender/Lien Holder Street Address, City State, Zip Actual Property Street Address, City State, Zip 20a.________________ ___________________ ___________________ __________________ __________________ __________________ Date Purchased Purchase Price Current Balance Monthly Payment ____________ $____________ $_________ $_________ 20b.________________ __________________ ____________ $____________ $_________ $_________ ___________________ __________________ ___________________ __________________ ____________________________________________________________________________________________ 21. PERSONAL ASSETS. List all personal assets below. (If you need additional space, attach a separate sheet.) Line 21a. Furniture/Personal effects includes the total current market value of your household such as furniture and appliances. Line 21b. Other includes all jewelry, artwork, antiques, collections and/or other assets not already listed on this statement. Current Loan Monthly Description Value Balance Lender Payment 21a. Furniture/Personal Effects $___________ $____________ ____________________ $__________ (see note above) 21b. Other (see note above) __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ Name_____________________________ Section 8 SSN_____________________ TOTAL INCOME Expense Items (W e generally do not allow you to claim tuition for private schools, college expenses, charitable donations, or voluntary retirement contributions.) Source Even if only one spouse has a debt, but both have income, list the total household income and expenses. 5 TOTAL LIVING EXPENSES Monthly Income and Expense NOTE: Page Monthly 22a. Gross Wages (you) $__________ 22b. Gross W ages (spouse) $__________ 22c. Interest/Dividends $__________ 22d. Net Business Income $__________ 22e. Net Rental Income $__________ 22f. Pension/Social Security (you) 22g. Pension/Social Security (spouse) 22h. Child Support 22i. Alimony 22j. Other $__________ $__________ $__________ $__________ $__________ DEDUCTIONS FROM W AGES (including spouses) Monthly 24a. Taxes (Federal, $__________ State, FICA, etc.) 24b. Insurance $__________ 24c. Union Dues $__________ 24d. Other (specify) ___________________ $__________ ___________________ $__________ Items 23a. Rent/Mortgage 23b. Electric 23c. Natural Gas 23d. Cable TV 23e. Telephone 23f. W ater 23g. Food 23h. Car Payment 23i. Gasoline 23j. Car Insurance 23k. Cell Phone/Pager 23l. Clothing & Misc. 23m. Court Ordered Payments 23n. Child Support 23o. Child/Dependant Care 23p. Life Insurance 23q. Other expenses (specify) _____________________ _______________________ _____________________ _______________________ Actual Monthly $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ Ú Ú Ú Ú Ú ATTACHM ENTS REQUIRED. Please include: C A copy of your last Form 1040 with all schedules C Proof of all current expenses that you paid for last 3 months, including utilities, rent, insurance, property taxes, etc. C Copies of any court order requiring payment and proof of such payments for the last 3 months. C Copies of any paperwork to support claims on lines 22j, 23q or 24d. PAYM ENTS PROPOSED M ONTHLY PAYM ENT IS: $_____________ ON ________ DAY OF THE M ONTH. CERTIFICATION I declare that I have examined the information given in this statement and, to the best of my knowledge and belief, it is true, correct and complete, and I further declare that I have no assets, owned either directly or indirectly or income of any nature other than as shown in this statement, including any attachment. ________________________________________________________________________________________________________ Signature Social Security No. Date W ARNING False statements are punishable up to five years imprisonment, a fine of $250,000 or both pursuant to 18 U.S.C. §1001. ATTACHMENT A 1. Earning statements from your most recent paychecks. 2. Business records for the present year and past calendar year which reflect assets, liabilities, gross receipts and expenses for any sole proprietorship, partnership or corporation in which you, or your spouse, own any interest. 3. Current bank statements for the past 12 months from all banks or other financial institutions, where any sole proprietorship, partnership, or corporation in which you, or your spouse, own any interest, has an account of any kind. 4. Current bank statements for the past 12 months from all banks, or other institutions, where you, or your spouse, have an account of any kind. 5. All trust agreements in which you, or your spouse, are named trustor, trustee or beneficiary. 6. All deeds, leases, contracts, and other documents representing any ownership interest you, or your spouse, have in any real property, and all deeds of thrust, mortgages, or other documents evidencing encumbrances of any kind on your real property. 7. All stocks, bonds, or other securities of any class you may own, by you separately or jointly with others, including options to purchase any securities. 8. Titles to all motor vehicles owned by you or your spouse. 9. All life insurance policies in which you are either the insured or the beneficiary. 10. All promissory notes held by you, and all other documents evidencing any money owed to you either now or in the future. 11. All financial statements furnished by you within the past five years. 12. All deeds, bills of sale, or other documents prepared in connection with any transfer made by you, either by gift, sale, or otherwise within the last five years. 13. A schedule of all regular expenses paid by you, such as installment debts, food, utilities, etc. Include the amount paid, the payee, and, if an installment debt, the amount of debt owing and any security pledged. 14. All documents evidencing any interest you have in any pension plan, retirement fund, or profit-sharing plan. 15. All records pertaining to your assets and finances. 16. Copies of income tax returns for the past three years. 17. All records of any unincorporated business of which you are an owner or partowner, or have been an owner within the past three years.
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