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<br />Y. MJJCIJ <br />A. Do the persons whose income or contributions are included in item above: <br />1) have savings, stocks, bonds, equity in real property or other form of capital <br />investment (excluding the values of necessary items of personal property such as <br />furniture and automobiles and interests in Indian trust land); or <br />No Yes <br />2) have they disposed of any assets (other than at a foreclosure or Credit Bankruptcy <br />sale) during the last two years at less than fair market value? <br />No Yes <br />3) If the answer to (1) or (2) above is yes, does the combined total value of all such <br />assets owned or disposed of by all such persons total more than $5,000? <br />No Yes <br />(4) If the answer to (3) above is yes, state the amount of income expected to be <br />derived from such assets in the 12-month period beginning on the date of initial <br />occupancy: <br />B. Do you own any real property? <br />No Yes <br />1) If yes to answer B above, provide: <br />Address: <br />Monthly Income:_ <br />D. Checking and Savings Accounts: <br />Please identify the checking and savings accounts of all adult household members who will use the home as <br />their permanent residence. This information may be provided on a combined basis by both married and <br />unmarried persons if the accounts are jointly held. <br />Name Name of Bank, S&L, Credit <br />Union Account Number Current Balance <br /> <br /> <br /> <br />