Schedule A - Cash, Checking Accounts, Savings Accounts, and Certificates of Deposit

Type Name of Financial Institution Amount In Name Of: Pledged? Yes or No
- - $ - -
- - $ - -
- - $ - -
- - $ - -
- - $ - -

Schedule B - U.S. Government, Listed, and Unlisted Securities (List on separate sheet if necessary)

No. of Shares or Face Value of Bonds Description * In Name Of: Market Value Pledged? Yes or No
- - - $ -
- - - $ -
- - - $ -
- - - $ -
- - - $ -

* Indicate if Securities are Restricted by Contract or SEC Regulations

Schedule C - Life Insurance Carried, Include Group

Face Amount Name of Company Owner Beneficiary Cash Surrender
Value and Loans
$ - - - -
$ - - - -
$ - - - -
$ - - - -
$ - - - -

Schedule D - Real Estate Owned

Address and Type of Property Date Acquired Title in Name Of: Cost Market Value Mortgage Amount Mortgage Maturity Insurance $
- - - $ $ - - $
- - - $ $ - - $
- - - $ $ - - $
- - - $ $ - - $
- - - $ $ - - $

Schedule E - Names of Banks or Finance Companies Where Credit Has Been Obtained

Name and Address of Lender Borrower Date Made Date Due High Credit Current Balance Secured or Unsecured
- - - - - $ -
- - - - - $ -
- - - - - $ -
- - - - - $ -
- - - - - $ -

The undersigned certifies that the information contained in this financial statement is true and correct and that you may consider this statement as continuing to be true and correct until a written notice of a change if given to you by the undersigned.

Sworn to before me on (date)

Signature


X
Notary Public, Wisconsin

Signature