SECTION A TO BE ANSWERED BY BANKING INSTITUTIONS
1. Does the named defendant have any checking, savings or other accounts at your bank? Yes ___ No ___
2. If yes, for all such accounts set forth the type of account, the account number and the current balance in the
account.
I hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing
statements made by me are willfully false, I am subject to punishment.
DATED:____________________ ________________
Signature
_______________________________
Print your name and title
SECTION B TO BE ANSWERED BY EMPLOYERS
1. Does the named defendant work for your business at the present time? Yes ___ No ___
2. If yes, set forth the named defendant's gross and net weekly salary, including any overtime if applicable.
3. If the named defendant is no longer employed by your business, and if you know, state the name and address
of the named defendant's current employer.
I hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing
statements made by me are willfully false, I am subject to punishment.
DATED:____________________ ________________________________________________
Signature
_______________________________________________________________
Print your name and title
SECTION C TO BE ANSWERED BY THOSE CONDUCTING BUSINESS WITH THE NAMED
DEFENDANT
1. Has your business ever purchased goods and/or services from the named defendant? Yes ___ No ___
2. Does your business presently purchase goods and/or services from the named defendant? YES ___ NO ___
3. In the future, will your business purchase goods and/or services from the named defendant? YES ___ NO ___
4. Does your business owe any money to the named defendant? YES _____ NO _____ If yes, state the amount
currently owed.
I hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing
statements made by me are willfully false, I am subject to punishment.
DATED:____________________ ________________________________________________
Signature
_______________________________________________________________
Print your name and title