Form DA Disclosure Of Assets And Financial Information {DA} | Pdf Fpdf Doc Docx | Official Federal Forms

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Form DA Disclosure Of Assets And Financial Information {DA} | Pdf Fpdf Doc Docx | Official Federal Forms

Form DA Disclosure Of Assets And Financial Information {DA}

This is a Official Federal Forms form that can be used for Securities And Exchange Commission.

Alternate TextLast updated: 3/7/2012

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Form D-A Model Disclosure of Assets and Financial Information Form Instructions: The Commission's Rules of Practice provide that under certain circumstances a respondent who asserts or intends to assert an inability to pay disgorgement, interest or penalties may be required to disclose certain financial information. See Rules 410 and 630. Unless otherwise ordered, this form may be used by individuals required to supply such information. Partnerships, corporations or other entities should submit a financial statement, including an income statement, balance sheet and federal tax returns for each year from the year of the earliest violation alleged against the entity in the order instituting proceedings to the present. The respondent filing this form is required promptly to notify the Commission of any material change in the answer to any question on this form. A respondent making financial information disclosures on this form or in another manner pursuant to the requirements of Rule 410 or Rule 630 may submit the form with a motion for a protective order pursuant to Rule 322 of the Commission's Rules of Practice. Any other person submitting this form may request that the Commission afford the information submitted confidential treatment under the Freedom of Information Act under the Commission's Freedom of Information Act ("FOIA") regulations, see 17 CFR 200.83. A request for confidential treatment allows the requester an opportunity to justify the need for confidentiality. A request for confidential treatment does not, however, guarantee confidentiality. Notwithstanding any request for a protective order or for confidential treatment, copies of the financial disclosure statement shall be served on the interested division and will be included in the record of the proceeding. See Rule 630(d). If confidential treatment is sought, notice that a financial disclosure statement and request for confidential treatment have been filed shall be served on all other parties. No party receiving information for which confidential treatment has been requested may transfer or convey the information to any person or entity not a party to the proceeding without the prior permission of the Commission or a hearing officer. American LegalNet, Inc. www.FormsWorkFlow.com United States of America Before the Securities and Exchange Commission In the Matter of ) ) ) ) ) ) Administrative Proceeding File No. 3- Part I: Summary Financial Disclosure Statement Full Name: Last First Middle A. Net Worth 1. Assets: (from Part II.B.) 2. Liabilities: (from Part II.C.) 3. Net W orth: (from Part II.D.) B. Income and Payments Received 1. Gross income reported on most recent federal tax filing: 2. Last 12 calendar months (from Part II.E.): * If this amount, divided by 12, does not equal your current monthly income, please explain the discrepancy on an attached sheet. * C. Expenses 1. Last 12 calendar months (from Part II.F.): * If this amount, divided by 12, does not equal your current monthly expenses, please explain the discrepancy on an attached sheet. * American LegalNet, Inc. www.FormsWorkFlow.com United States of America Before the Securities and Exchange Commission In the Matter of ) ) ) ) ) ) Administrative Proceeding File No. 3- Part II: Detailed Financial Disclosure Information Full Name: Last First Middle If this form is filled out by a respondent requesting a protective order pursuant to Rule of Practice 322 (17 CFR 201.322), please check the box below. PROTECTIVE ORDER REQUESTED. Disclosure of this document is prohibited unless specifically authorized below. This document should be placed in a nonpublic file. For Use Only by the Secretary of the Commission: By order of (date), the Commission authorized this form to be placed in a public file. (Signature of Secretary) American LegalNet, Inc. www.FormsWorkFlow.com A. Scope of Information Requested: Requests for information about you include a request for the same information about your spouse (unless you are legally separated and living apart), minor children and any other dependents. B. Assets: List all assets owned by you, directly or indirectly, and all assets that are subject to your enjoyment or control, regardless of whether legal title or ownership is held in your name. 1. 2. 3. 4. Cash Listed Securities Surrender Value of Insurance Loans, Notes, Accounts Receivable Due to You Real Estate C. Liabilities: List all your liabilities including, but not limited to, the items listed below. 1. Mortgages 2. Auto Loans 3. Credit Card Debt 4. Margin Loans 5. Insurance Policy Loans 5. 6. 7. 6. Installment Loans Furniture Jewelry, Art, Rugs, Silver Collectibles, Other Valuables Automobiles Unlisted Securities 7. Other Loans, Notes or Accounts Payable 8. Accrued Real Estate Taxes 9. Judgments/Settlements Owed 10. Other (Itemize): 8. 9. 10. Partnership Interests (non-securities) 11. Net Value of Ownership Interest in Business 12. IRA, Keogh, 401(k), Annuity or Pension Accounts 13. Other (Itemize): 11. 14. Total Assets Total Liabilities D. Net Worth (Assets Less Liabilities) American LegalNet, Inc. www.FormsWorkFlow.com E. Income/Payments Received List all income or other payments received from any source in the last 12 months by you, or by any other person or entity if you have any right, power or authority to control or enjoy the use of the money or property received by such other person or entity. Identify the source, the recipient and the amount of payment, including but not limited to the items listed below. Description/Purpose 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Salary/Wages Commissions/Advances Bonuses Dividends Interest Distributions of Capital Annuity, Pension Payments Rents/Royalties (net) Sales of Assets (net) Repayment of Loans Alimony/Child Support Gifts over $1,000 Payments by Others on Your Behalf (see section I below) Other (itemize): Source Amount 14. 15. 16. Total Income/Receipts If you anticipate unusual income in the coming 12 months, please explain. American LegalNet, Inc. www.FormsWorkFlow.com F. Expenses/Disbursements List all your expenditures for the past 12 months, including but not limited to the items listed below. Identify the purpose and the amount of each expenditure. Description 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Mortgage/Rent Food Utilities Payments on Loans Real Estate Taxes Insurance Premiums Medical Expenses Automobile Expenses Alimony/Child Support Income Taxes (federal, state and local) Other Expenses (itemize): Amou

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