First Name *<\/span><\/label><\/li>

Middle Initial <\/label><\/li>

Last Name *<\/span><\/label><\/li>

Your Email Address *<\/span><\/label><\/li>

Residence Address *<\/span><\/label>

Street Address<\/label><\/span>Apt, Suite, Bldg. (optional)<\/label><\/span>City<\/label><\/span>State \/ Province \/ Region<\/label><\/span>Postal \/ Zip Code<\/label><\/span><\/li>

Business Phone *<\/span><\/label><\/li>

Date of Birth *<\/span><\/label><\/li>

Social Security Number *<\/span><\/label><\/li>

Driver's License\/ID Number *<\/span><\/label><\/li>

State Issued *<\/span><\/label><\/li>

Date Issued *<\/span><\/label><\/li>

Expiration Date *<\/span><\/label><\/li>

Employer Name *<\/span><\/label><\/li>

Number of Years *<\/span><\/label><\/li>

Position or Occupation *<\/span><\/label><\/li>

Nearest relative not living with me. *<\/span><\/label><\/li>

Relationship *<\/span><\/label><\/li>

Phone *<\/span><\/label><\/li>

Address <\/label>

Street Address<\/label><\/span>Apt, Suite, Bldg. (optional)<\/label><\/span>City<\/label><\/span>State \/ Province \/ Region<\/label><\/span>Postal \/ Zip Code<\/label><\/span><\/li>

Middle Initial <\/label><\/li>

Last Name <\/label><\/li>

Residential Address <\/label>

Street Address<\/label><\/span>Apt, Suite, Bldg. (optional)<\/label><\/span>City<\/label><\/span>State \/ Province \/ Region<\/label><\/span>Postal \/ Zip Code<\/label><\/span><\/li>

Social Security Number <\/label><\/li>

Driver's License\/ID Number *<\/span><\/label><\/li>

State Issued <\/label><\/li>

Date Issued <\/label><\/li>

Expiration Date <\/label><\/li>

Residential Phone <\/label><\/li>

Business Phone <\/label><\/li>

Employer Name <\/label><\/li>

Position or Occupation <\/label><\/li>

Number Of Years <\/label><\/li>

Nearest relative not living with me <\/label><\/li>

Relationship <\/label><\/li>

Phone <\/label><\/li>

Address <\/label>

Street Address<\/label><\/span>Apt, Suite, Bldg. (optional)<\/label><\/span>City<\/label><\/span>State \/ Province \/ Region<\/label><\/span>Postal \/ Zip Code<\/label><\/span><\/li>

$ Savings Accounts <\/label><\/li>

$ IRA or Other Retirement Account <\/label><\/li>

$ Life Insurance-Cash Surrender Value Only <\/label>(Complete Section 8)<\/label><\/span><\/li>

$ Stocks and Bonds <\/label>(Describe in Section 3)<\/label><\/span><\/li>

$ Real Estate <\/label>(Describe in Section 4)<\/label><\/span><\/li>

$ Automobile-Present Value <\/label><\/li>

$ Other Personal Property <\/label>(Describe in Section 5)<\/label><\/span><\/li>

$ Other Assets <\/label>(Describe in Section 5)<\/label><\/span><\/li>

TOTAL <\/label>Total Dollar Amount of Assets<\/label><\/span><\/li>

LIABILITIES (omit cents)<\/h4><\/div>
<\/div>
$ Accounts Payable <\/label><\/li>
$ Notes Payable to Banks and Others <\/label>(Describe in Section 2)<\/label><\/span><\/li>
$ Installment Account (Auto) <\/label><\/li>
$ Mo. Payments <\/label><\/li>
$ Installment Account (Other) <\/label><\/li>
$ Mo. Payments <\/label><\/li>
$ Loan on Life Insurance <\/label><\/li>
$ Mortgages on Real Estate <\/label>(Describe in Section 4)<\/label><\/span><\/li>
$ Unpaid Taxes <\/label>(Describe in Section 6)<\/label><\/span><\/li>
$ Other Liabilities <\/label>(Describe in Section 7)<\/label><\/span><\/li>
TOTAL LIABILITIES <\/label><\/li>
NET WORTH <\/label><\/li>
TOTAL LIABILITIES AND NET WORTH <\/label><\/li><\/ul> <\/fieldset>
Section 1<\/h3><\/div>
Source of Income<\/h4><\/div>
<\/div>
$ Salary <\/label><\/li>
$ Net Investment Income <\/label><\/li>
$ Real Estate Income <\/label><\/li>
$ Other Income (Describe below)* <\/label><\/li>
Description of Other Income in Section 1. <\/label>
Alimony or child support payments need not be disclosed in \"Other Income\" unless it is desired to have such payments counted toward total income.<\/label><\/span><\/textarea><\/div><\/li><div id=\"item-vfb-253\" class=\"vfb-section-div \"><h4>Contingent Liabilities<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-currency \" id=\"item-vfb-254\"><label for=\"vfb-254\" class=\"vfb-desc\">$ As Endorser or Co-Maker <\/label><input type=\"text\" name=\"vfb-254\" id=\"vfb-254\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency \" id=\"item-vfb-255\"><label for=\"vfb-255\" class=\"vfb-desc\">$ Legal Claims & Judgments <\/label><input type=\"text\" name=\"vfb-255\" id=\"vfb-255\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency \" id=\"item-vfb-256\"><label for=\"vfb-256\" class=\"vfb-desc\">$ Provision for Federal Income Tax <\/label><input type=\"text\" name=\"vfb-256\" id=\"vfb-256\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency \" id=\"item-vfb-257\"><label for=\"vfb-257\" class=\"vfb-desc\">$ Other Special Debt <\/label><input type=\"text\" name=\"vfb-257\" id=\"vfb-257\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-4 section-2-notes-payable-to-banks-and-others \" id=\"item-vfb-258\"><div class=\"vfb-legend\"><h3>Section 2. Notes Payable to Banks and Others.<\/h3><\/div><ul class=\"vfb-section vfb-section-4\"><li class=\"vfb-item vfb-item-instructions \" id=\"item-vfb-274\"><label class=\"vfb-desc\">(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.) <\/label><\/li><div id=\"item-vfb-263\" class=\"vfb-section-div \"><h4>Noteholder #1<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-textarea vfb-left-third\" id=\"item-vfb-259\"><label for=\"vfb-259\" class=\"vfb-desc\">Name and Address of Noteholder(s) <\/label><div><textarea name=\"vfb-259\" id=\"vfb-259\" class=\"vfb-textarea vfb-medium \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-text vfb-middle-third\" id=\"item-vfb-260\"><label for=\"vfb-260\" class=\"vfb-desc\">How Secured or Endorsed \/Type of Collateral <\/label><input type=\"text\" name=\"vfb-260\" id=\"vfb-260\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-261\"><label for=\"vfb-261\" class=\"vfb-desc\">$ Original Balance <\/label><input type=\"text\" name=\"vfb-261\" id=\"vfb-261\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-264\"><label for=\"vfb-264\" class=\"vfb-desc\">$ Current Balance <\/label><input type=\"text\" name=\"vfb-264\" id=\"vfb-264\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-middle-third\" id=\"item-vfb-265\"><label for=\"vfb-265\" class=\"vfb-desc\">$ Payment Amount <\/label><input type=\"text\" name=\"vfb-265\" id=\"vfb-265\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-right-third\" id=\"item-vfb-267\"><label for=\"vfb-267\" class=\"vfb-desc\">Payment Frequency <\/label><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-267\" id=\"vfb-267\" value=\"\" class=\"vfb-text vfb-medium \" \/><label>(monthly, etc)<\/label><\/span><\/li><div id=\"item-vfb-275\" class=\"vfb-section-div \"><h4>Noteholder #2<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-textarea vfb-left-third\" id=\"item-vfb-268\"><label for=\"vfb-268\" class=\"vfb-desc\">Name and Address of Noteholder(s) <\/label><div><textarea name=\"vfb-268\" id=\"vfb-268\" class=\"vfb-textarea vfb-medium \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-text vfb-middle-third\" id=\"item-vfb-269\"><label for=\"vfb-269\" class=\"vfb-desc\">How Secured or Endorsed \/Type of Collateral <\/label><input type=\"text\" name=\"vfb-269\" id=\"vfb-269\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-270\"><label for=\"vfb-270\" class=\"vfb-desc\">$ Original Balance <\/label><input type=\"text\" name=\"vfb-270\" id=\"vfb-270\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-271\"><label for=\"vfb-271\" class=\"vfb-desc\">$ Current Balance <\/label><input type=\"text\" name=\"vfb-271\" id=\"vfb-271\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-middle-third\" id=\"item-vfb-272\"><label for=\"vfb-272\" class=\"vfb-desc\">$ Payment Amount <\/label><input type=\"text\" name=\"vfb-272\" id=\"vfb-272\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-right-third\" id=\"item-vfb-273\"><label for=\"vfb-273\" class=\"vfb-desc\">Payment Frequency <\/label><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-273\" id=\"vfb-273\" value=\"\" class=\"vfb-text vfb-medium \" \/><label>(monthly, etc)<\/label><\/span><\/li><div id=\"item-vfb-276\" class=\"vfb-section-div \"><h4>Noteholder #3<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-textarea vfb-left-third\" id=\"item-vfb-277\"><label for=\"vfb-277\" class=\"vfb-desc\">Name and Address of Noteholder(s) <\/label><div><textarea name=\"vfb-277\" id=\"vfb-277\" class=\"vfb-textarea vfb-medium \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-text vfb-middle-third\" id=\"item-vfb-278\"><label for=\"vfb-278\" class=\"vfb-desc\">How Secured or Endorsed \/Type of Collateral <\/label><input type=\"text\" name=\"vfb-278\" id=\"vfb-278\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-279\"><label for=\"vfb-279\" class=\"vfb-desc\">$ Original Balance <\/label><input type=\"text\" name=\"vfb-279\" id=\"vfb-279\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-280\"><label for=\"vfb-280\" class=\"vfb-desc\">$ Current Balance <\/label><input type=\"text\" name=\"vfb-280\" id=\"vfb-280\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-middle-third\" id=\"item-vfb-281\"><label for=\"vfb-281\" class=\"vfb-desc\">$ Payment Amount <\/label><input type=\"text\" name=\"vfb-281\" id=\"vfb-281\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-right-third\" id=\"item-vfb-282\"><label for=\"vfb-282\" class=\"vfb-desc\">Payment Frequency <\/label><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-282\" id=\"vfb-282\" value=\"\" class=\"vfb-text vfb-medium \" \/><label>(monthly, etc)<\/label><\/span><\/li><div id=\"item-vfb-287\" class=\"vfb-section-div \"><h4>If you have additional attachments, please upload here. Each attachment must be identified as a part of this statement and signed.)<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-283\"><label for=\"vfb-283\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-283\" id=\"vfb-283\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif}tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-285\"><label for=\"vfb-285\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-285\" id=\"vfb-285\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif}tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-286\"><label for=\"vfb-286\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-286\" id=\"vfb-286\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif}tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><li class=\"vfb-item vfb-item-instructions \" id=\"item-vfb-306\"><label class=\"vfb-desc\">IMPORTANT: Please submit this portion and continue to Page 2 below. A copy of your entries will be automatically emailed to you. <\/label><\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-5 verification \" id=\"item-vfb-169\" style=\"display:block\"><div class=\"vfb-legend\"><h3>Verification<\/h3><\/div><ul class=\"vfb-section vfb-section-5\"><li class=\"vfb-item vfb-item-secret\" style=\"display:block\"><label for=\"vfb-170\" class=\"vfb-desc\">Please enter any two digits <span class=\"vfb-required-asterisk\"><\/span><\/label><input type=\"hidden\" name=\"_vfb-secret\" value=\"vfb-170\" \/><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-170\" id=\"vfb-170\" value=\"\" class=\"vfb-text vfb-medium required {digits:true,maxlength:2,minlength:2} \" style=\"display:block\" \/><label>Example: 12<\/label><\/span><li style=\"display:none;\"><label>This box is for spam protection - <strong>please leave it blank<\/strong>:<\/label><div><input name=\"vfb-spam\" \/><\/div><\/li>\n\t\t\t<li class=\"vfb-item vfb-item-submit\" id=\"item-vfb-171\">\n\t\t\t\t<input type=\"submit\" name=\"vfb-submit\" id=\"vfb-171\" value=\"Submit\" class=\"vfb-submit \" \/>\n\t\t\t\t<\/li><\/ul>\n\t\t\t<\/fieldset><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F4480\" \/><\/form><\/div> <br \/>\n<div id=\"vfb-form-6\" class=\"visual-form-builder-container\"><form id=\"personal-financial-statement-page-2-6\" class=\"visual-form-builder vfb-form-6 \" method=\"post\" enctype=\"multipart\/form-data\">\n\t \t<input type=\"hidden\" name=\"form_id\" value=\"6\" \/><fieldset class=\"vfb-fieldset vfb-fieldset-1 personal-financial-statement-page-2 \" id=\"item-vfb-311\"><div class=\"vfb-legend\"><h3>Personal Financial Statement Page 2<\/h3><\/div><ul class=\"vfb-section vfb-section-1\"><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-2 section-3-stocks-and-bonds \" id=\"item-vfb-316\"><div class=\"vfb-legend\"><h3>Section 3- Stocks and Bonds<\/h3><\/div><ul class=\"vfb-section vfb-section-2\"><div id=\"item-vfb-317\" class=\"vfb-section-div \"><h4>Securities #1<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-318\"><label for=\"vfb-318\" class=\"vfb-desc\">Name of Securities <\/label><input type=\"text\" name=\"vfb-318\" id=\"vfb-318\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-number vfb-middle-third\" id=\"item-vfb-319\"><label for=\"vfb-319\" class=\"vfb-desc\">Number of Shares <\/label><input type=\"text\" name=\"vfb-319\" id=\"vfb-319\" value=\"\" class=\"vfb-text vfb-medium digits \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-320\"><label for=\"vfb-320\" class=\"vfb-desc\">$ Cost <\/label><input type=\"text\" name=\"vfb-320\" id=\"vfb-320\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-321\"><label for=\"vfb-321\" class=\"vfb-desc\">$ Market Value\/Quotation\/Exchange <\/label><input type=\"text\" name=\"vfb-321\" id=\"vfb-321\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-date vfb-middle-third\" id=\"item-vfb-322\"><label for=\"vfb-322\" class=\"vfb-desc\">Date of Quotation\/Exchange <\/label><input type=\"text\" name=\"vfb-322\" id=\"vfb-322\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-323\"><label for=\"vfb-323\" class=\"vfb-desc\">$ Total Value <\/label><input type=\"text\" name=\"vfb-323\" id=\"vfb-323\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><div id=\"item-vfb-324\" class=\"vfb-section-div \"><h4>Securities #2<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-325\"><label for=\"vfb-325\" class=\"vfb-desc\">Name of Securities <\/label><input type=\"text\" name=\"vfb-325\" id=\"vfb-325\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-number vfb-middle-third\" id=\"item-vfb-326\"><label for=\"vfb-326\" class=\"vfb-desc\">Number of Shares <\/label><input type=\"text\" name=\"vfb-326\" id=\"vfb-326\" value=\"\" class=\"vfb-text vfb-medium digits \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-327\"><label for=\"vfb-327\" class=\"vfb-desc\">$ Cost <\/label><input type=\"text\" name=\"vfb-327\" id=\"vfb-327\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-328\"><label for=\"vfb-328\" class=\"vfb-desc\">$Market Value\/Quotation\/Exchange <\/label><input type=\"text\" name=\"vfb-328\" id=\"vfb-328\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-date vfb-middle-third\" id=\"item-vfb-329\"><label for=\"vfb-329\" class=\"vfb-desc\">Date of Quotation\/Exchange <\/label><input type=\"text\" name=\"vfb-329\" id=\"vfb-329\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-330\"><label for=\"vfb-330\" class=\"vfb-desc\">$ Total Value <\/label><input type=\"text\" name=\"vfb-330\" id=\"vfb-330\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><div id=\"item-vfb-331\" class=\"vfb-section-div \"><h4>Securities #2<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-332\"><label for=\"vfb-332\" class=\"vfb-desc\">Name of Securities <\/label><input type=\"text\" name=\"vfb-332\" id=\"vfb-332\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-number vfb-middle-third\" id=\"item-vfb-333\"><label for=\"vfb-333\" class=\"vfb-desc\">Number of Shares <\/label><input type=\"text\" name=\"vfb-333\" id=\"vfb-333\" value=\"\" class=\"vfb-text vfb-medium digits \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-334\"><label for=\"vfb-334\" class=\"vfb-desc\">$ Cost <\/label><input type=\"text\" name=\"vfb-334\" id=\"vfb-334\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-335\"><label for=\"vfb-335\" class=\"vfb-desc\">$ Market Value\/Quotation\/Exchange <\/label><input type=\"text\" name=\"vfb-335\" id=\"vfb-335\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-date vfb-middle-third\" id=\"item-vfb-336\"><label for=\"vfb-336\" class=\"vfb-desc\">Date of Quotation\/Exchange <\/label><input type=\"text\" name=\"vfb-336\" id=\"vfb-336\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-third\" id=\"item-vfb-337\"><label for=\"vfb-337\" class=\"vfb-desc\">$ Total Value <\/label><input type=\"text\" name=\"vfb-337\" id=\"vfb-337\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><div id=\"item-vfb-338\" class=\"vfb-section-div \"><h4>If you have additional attachments, please upload here. Each attachment must be identified as a part of this statement and signed.)<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-339\"><label for=\"vfb-339\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-339\" id=\"vfb-339\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif|tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-340\"><label for=\"vfb-340\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-340\" id=\"vfb-340\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif|tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-341\"><label for=\"vfb-341\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-341\" id=\"vfb-341\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif|tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-3 section-4-real-estate-owned \" id=\"item-vfb-342\"><div class=\"vfb-legend\"><h3>Section 4. Real Estate Owned<\/h3><\/div><ul class=\"vfb-section vfb-section-3\"><div id=\"item-vfb-344\" class=\"vfb-section-div \"><h4>Property A<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-345\"><label for=\"vfb-345\" class=\"vfb-desc\">Type of Property <\/label><input type=\"text\" name=\"vfb-345\" id=\"vfb-345\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-address vfb-middle-third\" id=\"item-vfb-346\"><label class=\"vfb-desc\">Address <\/label><div><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-346[address]\" id=\"vfb-346-address\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-346-address\">Street Address<\/label><\/span><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-346[address-2]\" id=\"vfb-346-address-2\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-346-address-2\">Apt, Suite, Bldg. (optional)<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-346[city]\" id=\"vfb-346-city\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-346-city\">City<\/label><\/span><span class=\"vfb-right\"><input type=\"text\" name=\"vfb-346[state]\" id=\"vfb-346-state\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-346-state\">State \/ Province \/ Region<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-346[zip]\" id=\"vfb-346-zip\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-346-zip\">Postal \/ Zip Code<\/label><\/span><span class=\"vfb-right\"><select name=\"vfb-346[country]\" class=\"vfb-select \" id=\"vfb-346-country\"><option value=\"\" selected='selected'><\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo (Brazzaville)\">Congo (Brazzaville)<\/option><option value=\"Congo\">Congo<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d\\'Ivoire\">Cote d\\'Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"East Timor (Timor Timur)\">East Timor (Timor Timur)<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia, The\">Gambia, The<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, North\">Korea, North<\/option><option value=\"Korea, South\">Korea, South<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palestinian Territory\">Palestinian Territory<\/option><option value=\"Palau\">Palau<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent\">Saint Vincent<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican City\">Vatican City<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Western Samoa\">Western Samoa<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><label for=\"vfb-346-country\">Country<\/label><\/span><\/div><\/li><li class=\"vfb-item vfb-item-date vfb-right-third\" id=\"item-vfb-347\"><label for=\"vfb-347\" class=\"vfb-desc\">Date Purchased <\/label><input type=\"text\" name=\"vfb-347\" id=\"vfb-347\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-half\" id=\"item-vfb-348\"><label for=\"vfb-348\" class=\"vfb-desc\">Original Cost <\/label><input type=\"text\" name=\"vfb-348\" id=\"vfb-348\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-half\" id=\"item-vfb-349\"><label for=\"vfb-349\" class=\"vfb-desc\">Present Market Value <\/label><input type=\"text\" name=\"vfb-349\" id=\"vfb-349\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-left-half\" id=\"item-vfb-350\"><label for=\"vfb-350\" class=\"vfb-desc\">Name & Address of Mortgage Holder <\/label><input type=\"text\" name=\"vfb-350\" id=\"vfb-350\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-number vfb-right-half\" id=\"item-vfb-351\"><label for=\"vfb-351\" class=\"vfb-desc\">Mortgage Account Number <\/label><input type=\"text\" name=\"vfb-351\" id=\"vfb-351\" value=\"\" class=\"vfb-text vfb-medium digits \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-352\"><label for=\"vfb-352\" class=\"vfb-desc\">Mortgage Balance <\/label><input type=\"text\" name=\"vfb-352\" id=\"vfb-352\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-middle-third\" id=\"item-vfb-353\"><label for=\"vfb-353\" class=\"vfb-desc\">Amount of Payment per Month\/Year <\/label><input type=\"text\" name=\"vfb-353\" id=\"vfb-353\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-right-third\" id=\"item-vfb-354\"><label for=\"vfb-354\" class=\"vfb-desc\">Status of Mortgage <\/label><input type=\"text\" name=\"vfb-354\" id=\"vfb-354\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><div id=\"item-vfb-355\" class=\"vfb-section-div \"><h4>Property B<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-356\"><label for=\"vfb-356\" class=\"vfb-desc\">Type of Property <\/label><input type=\"text\" name=\"vfb-356\" id=\"vfb-356\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-address vfb-middle-third\" id=\"item-vfb-357\"><label class=\"vfb-desc\">Address <\/label><div><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-357[address]\" id=\"vfb-357-address\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-357-address\">Street Address<\/label><\/span><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-357[address-2]\" id=\"vfb-357-address-2\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-357-address-2\">Apt, Suite, Bldg. (optional)<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-357[city]\" id=\"vfb-357-city\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-357-city\">City<\/label><\/span><span class=\"vfb-right\"><input type=\"text\" name=\"vfb-357[state]\" id=\"vfb-357-state\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-357-state\">State \/ Province \/ Region<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-357[zip]\" id=\"vfb-357-zip\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-357-zip\">Postal \/ Zip Code<\/label><\/span><span class=\"vfb-right\"><select name=\"vfb-357[country]\" class=\"vfb-select \" id=\"vfb-357-country\"><option value=\"\" selected='selected'><\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo (Brazzaville)\">Congo (Brazzaville)<\/option><option value=\"Congo\">Congo<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d\\'Ivoire\">Cote d\\'Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"East Timor (Timor Timur)\">East Timor (Timor Timur)<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia, The\">Gambia, The<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, North\">Korea, North<\/option><option value=\"Korea, South\">Korea, South<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palestinian Territory\">Palestinian Territory<\/option><option value=\"Palau\">Palau<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent\">Saint Vincent<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican City\">Vatican City<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Western Samoa\">Western Samoa<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><label for=\"vfb-357-country\">Country<\/label><\/span><\/div><\/li><li class=\"vfb-item vfb-item-date vfb-right-third\" id=\"item-vfb-358\"><label for=\"vfb-358\" class=\"vfb-desc\">Date Purchased <\/label><input type=\"text\" name=\"vfb-358\" id=\"vfb-358\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-half\" id=\"item-vfb-359\"><label for=\"vfb-359\" class=\"vfb-desc\">Original Cost <\/label><input type=\"text\" name=\"vfb-359\" id=\"vfb-359\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-half\" id=\"item-vfb-360\"><label for=\"vfb-360\" class=\"vfb-desc\">Present Market Value <\/label><input type=\"text\" name=\"vfb-360\" id=\"vfb-360\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-left-half\" id=\"item-vfb-361\"><label for=\"vfb-361\" class=\"vfb-desc\">Name & Address of Mortgage Holder <\/label><input type=\"text\" name=\"vfb-361\" id=\"vfb-361\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-number vfb-right-half\" id=\"item-vfb-362\"><label for=\"vfb-362\" class=\"vfb-desc\">Mortgage Account Number <\/label><input type=\"text\" name=\"vfb-362\" id=\"vfb-362\" value=\"\" class=\"vfb-text vfb-medium digits \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-363\"><label for=\"vfb-363\" class=\"vfb-desc\">Mortgage Balance <\/label><input type=\"text\" name=\"vfb-363\" id=\"vfb-363\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-middle-third\" id=\"item-vfb-364\"><label for=\"vfb-364\" class=\"vfb-desc\">Amount of Payment per Month\/Year <\/label><input type=\"text\" name=\"vfb-364\" id=\"vfb-364\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-right-third\" id=\"item-vfb-365\"><label for=\"vfb-365\" class=\"vfb-desc\">Status of Mortgage <\/label><input type=\"text\" name=\"vfb-365\" id=\"vfb-365\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><div id=\"item-vfb-366\" class=\"vfb-section-div \"><h4>Property C<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-367\"><label for=\"vfb-367\" class=\"vfb-desc\">Type of Property <\/label><input type=\"text\" name=\"vfb-367\" id=\"vfb-367\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-address vfb-middle-third\" id=\"item-vfb-368\"><label class=\"vfb-desc\">Address <\/label><div><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-368[address]\" id=\"vfb-368-address\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-368-address\">Street Address<\/label><\/span><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-368[address-2]\" id=\"vfb-368-address-2\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-368-address-2\">Apt, Suite, Bldg. (optional)<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-368[city]\" id=\"vfb-368-city\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-368-city\">City<\/label><\/span><span class=\"vfb-right\"><input type=\"text\" name=\"vfb-368[state]\" id=\"vfb-368-state\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-368-state\">State \/ Province \/ Region<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-368[zip]\" id=\"vfb-368-zip\" maxlength=\"150\" class=\"vfb-text vfb-medium \" \/><label for=\"vfb-368-zip\">Postal \/ Zip Code<\/label><\/span><span class=\"vfb-right\"><select name=\"vfb-368[country]\" class=\"vfb-select \" id=\"vfb-368-country\"><option value=\"\" selected='selected'><\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo (Brazzaville)\">Congo (Brazzaville)<\/option><option value=\"Congo\">Congo<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d\\'Ivoire\">Cote d\\'Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"East Timor (Timor Timur)\">East Timor (Timor Timur)<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia, The\">Gambia, The<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, North\">Korea, North<\/option><option value=\"Korea, South\">Korea, South<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palestinian Territory\">Palestinian Territory<\/option><option value=\"Palau\">Palau<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent\">Saint Vincent<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican City\">Vatican City<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Western Samoa\">Western Samoa<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><label for=\"vfb-368-country\">Country<\/label><\/span><\/div><\/li><li class=\"vfb-item vfb-item-date vfb-right-third\" id=\"item-vfb-369\"><label for=\"vfb-369\" class=\"vfb-desc\">Date Purchased <\/label><input type=\"text\" name=\"vfb-369\" id=\"vfb-369\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-half\" id=\"item-vfb-370\"><label for=\"vfb-370\" class=\"vfb-desc\">Original Cost <\/label><input type=\"text\" name=\"vfb-370\" id=\"vfb-370\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-right-half\" id=\"item-vfb-371\"><label for=\"vfb-371\" class=\"vfb-desc\">Present Market Value <\/label><input type=\"text\" name=\"vfb-371\" id=\"vfb-371\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-left-half\" id=\"item-vfb-372\"><label for=\"vfb-372\" class=\"vfb-desc\">Name & Address of Mortgage Holder <\/label><input type=\"text\" name=\"vfb-372\" id=\"vfb-372\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><li class=\"vfb-item vfb-item-number vfb-right-half\" id=\"item-vfb-373\"><label for=\"vfb-373\" class=\"vfb-desc\">Mortgage Account Number <\/label><input type=\"text\" name=\"vfb-373\" id=\"vfb-373\" value=\"\" class=\"vfb-text vfb-medium digits \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-left-third\" id=\"item-vfb-374\"><label for=\"vfb-374\" class=\"vfb-desc\">Mortgage Balance <\/label><input type=\"text\" name=\"vfb-374\" id=\"vfb-374\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-currency vfb-middle-third\" id=\"item-vfb-375\"><label for=\"vfb-375\" class=\"vfb-desc\">Amount of Payment per Month\/Year <\/label><input type=\"text\" name=\"vfb-375\" id=\"vfb-375\" value=\"\" class=\"vfb-text vfb-medium number \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-right-third\" id=\"item-vfb-376\"><label for=\"vfb-376\" class=\"vfb-desc\">Status of Mortgage <\/label><input type=\"text\" name=\"vfb-376\" id=\"vfb-376\" value=\"\" class=\"vfb-text vfb-medium \" \/><\/li><div id=\"item-vfb-377\" class=\"vfb-section-div \"><h4>If you have additional attachments, please upload here. Each attachment must be identified as a part of this statement and signed.)<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-378\"><label for=\"vfb-378\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-378\" id=\"vfb-378\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif|tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-379\"><label for=\"vfb-379\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-379\" id=\"vfb-379\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif|tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><li class=\"vfb-item vfb-item-file-upload \" id=\"item-vfb-380\"><label for=\"vfb-380\" class=\"vfb-desc\">File Upload <\/label><span class=\"vfb-span\"><input type=\"file\" name=\"vfb-380\" id=\"vfb-380\" value=\"\" class=\"vfb-text vfb-medium {accept:'png|jpe?g|gif|tiff|pdf'}\" \/><label>Upload Additional Attachments<\/label><\/span><\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-4 section-5-other-personal-property-and-other-assets \" id=\"item-vfb-381\"><div class=\"vfb-legend\"><h3>Section 5. Other Personal Property and Other Assets<\/h3><\/div><ul class=\"vfb-section vfb-section-4\"><li class=\"vfb-item vfb-item-textarea \" id=\"item-vfb-384\"><label for=\"vfb-384\" class=\"vfb-desc\">(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency) <\/label><div><textarea name=\"vfb-384\" id=\"vfb-384\" class=\"vfb-textarea vfb-medium \"><\/textarea><\/div><\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-5 section-6-unpaid-taxes \" id=\"item-vfb-385\"><div class=\"vfb-legend\"><h3>Section 6. Unpaid Taxes<\/h3><\/div><ul class=\"vfb-section vfb-section-5\"><li class=\"vfb-item vfb-item-textarea \" id=\"item-vfb-387\"><label for=\"vfb-387\" class=\"vfb-desc\">(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.) <\/label><div><textarea name=\"vfb-387\" id=\"vfb-387\" class=\"vfb-textarea vfb-medium \"><\/textarea><\/div><\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-6 section-7-other-liabilities \" id=\"item-vfb-388\"><div class=\"vfb-legend\"><h3>Section 7. Other Liabilities.<\/h3><\/div><ul class=\"vfb-section vfb-section-6\"><li class=\"vfb-item vfb-item-textarea \" id=\"item-vfb-390\"><label for=\"vfb-390\" class=\"vfb-desc\">(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency) <\/label><div><textarea name=\"vfb-390\" id=\"vfb-390\" class=\"vfb-textarea vfb-medium \"><\/textarea><\/div><\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-7 section-8-life-insurance-held \" id=\"item-vfb-391\"><div class=\"vfb-legend\"><h3>Section 8. Life Insurance Held.<\/h3><\/div><ul class=\"vfb-section vfb-section-7\"><li class=\"vfb-item vfb-item-textarea \" id=\"item-vfb-394\"><label for=\"vfb-394\" class=\"vfb-desc\">(Give face amount and cash surrender value of policies - name of insurance company and beneficiaries) <\/label><div><textarea name=\"vfb-394\" id=\"vfb-394\" class=\"vfb-textarea vfb-medium \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-instructions \" id=\"item-vfb-393\"><label class=\"vfb-desc\">Authorization <\/label>I authorize Barthelemy Commercial Capital\/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above\r\nand the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining\r\na loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General\r\n(Reference 18 U.S.C. 1001).<\/li><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-395\"><label for=\"vfb-395\" class=\"vfb-desc\">Electronic Signature <span class=\"vfb-required-asterisk\"><\/span><\/label><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-395\" id=\"vfb-395\" value=\"\" class=\"vfb-text vfb-medium required \" \/><label>Type Name<\/label><\/span><\/li><li class=\"vfb-item vfb-item-date vfb-middle-third\" id=\"item-vfb-396\"><label for=\"vfb-396\" class=\"vfb-desc\">Date <span class=\"vfb-required-asterisk\"><\/span><\/label><input type=\"text\" name=\"vfb-396\" id=\"vfb-396\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium required \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-number vfb-right-third\" id=\"item-vfb-397\"><label for=\"vfb-397\" class=\"vfb-desc\">Social Security Number <span class=\"vfb-required-asterisk\"><\/span><\/label><input type=\"text\" name=\"vfb-397\" id=\"vfb-397\" value=\"\" class=\"vfb-text vfb-medium required digits \" \/><\/li><li class=\"vfb-item vfb-item-email \" id=\"item-vfb-401\"><label for=\"vfb-401\" class=\"vfb-desc\">Email <span class=\"vfb-required-asterisk\"><\/span><\/label><input type=\"email\" name=\"vfb-401\" id=\"vfb-401\" value=\"\" class=\"vfb-text vfb-medium required email \" \/><\/li><li class=\"vfb-item vfb-item-text vfb-left-third\" id=\"item-vfb-398\"><label for=\"vfb-398\" class=\"vfb-desc\">Co-Applicant Electronic Signature (If applicable) <\/label><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-398\" id=\"vfb-398\" value=\"\" class=\"vfb-text vfb-medium \" \/><label>Type Name<\/label><\/span><\/li><li class=\"vfb-item vfb-item-date vfb-middle-third\" id=\"item-vfb-399\"><label for=\"vfb-399\" class=\"vfb-desc\">Date <\/label><input type=\"text\" name=\"vfb-399\" id=\"vfb-399\" value=\"\" class=\"vfb-text vfb-date-picker vfb-medium \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-number vfb-right-third\" id=\"item-vfb-400\"><label for=\"vfb-400\" class=\"vfb-desc\">Co-Applicant Social Security Number (if applicable) <\/label><input type=\"text\" name=\"vfb-400\" id=\"vfb-400\" value=\"\" class=\"vfb-text vfb-medium digits \" \/><\/li><li class=\"vfb-item vfb-item-instructions \" id=\"item-vfb-402\"><label class=\"vfb-desc\">End of Form <\/label>Please submit this portion. A copy of your entries will be automatically emailed to you<\/li><\/ul> <\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-8 verification \" id=\"item-vfb-312\" style=\"display:block\"><div class=\"vfb-legend\"><h3>Verification<\/h3><\/div><ul class=\"vfb-section vfb-section-8\"><li class=\"vfb-item vfb-item-secret\" style=\"display:block\"><label for=\"vfb-313\" class=\"vfb-desc\">Please enter any two digits <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"hidden\" name=\"_vfb-secret\" value=\"vfb-313\" \/><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-313\" id=\"vfb-313\" value=\"\" class=\"vfb-text vfb-medium required {digits:true,maxlength:2,minlength:2} \" style=\"display:block\" \/><label>Example: 12<\/label><\/span><li style=\"display:none;\"><label>This box is for spam protection - <strong>please leave it blank<\/strong>:<\/label><div><input name=\"vfb-spam\" \/><\/div><\/li>\n\t\t\t<li class=\"vfb-item vfb-item-submit\" id=\"item-vfb-314\">\n\t\t\t\t<input type=\"submit\" name=\"vfb-submit\" id=\"vfb-314\" value=\"Submit\" class=\"vfb-submit \" \/>\n\t\t\t\t<\/li><\/ul>\n\t\t\t<\/fieldset><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F4480\" \/><\/form><\/div> <\/p>\n<div id=\"themify_builder_content-4480\" data-postid=\"4480\" class=\"themify_builder_content themify_builder_content-4480 themify_builder\">\n <\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"jetpack_post_was_ever_published":false},"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/P28eiv-1ag","builder_content":"","_links":{"self":[{"href":"https:\/\/barthelemycc.com\/index.php?rest_route=\/wp\/v2\/pages\/4480"}],"collection":[{"href":"https:\/\/barthelemycc.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/barthelemycc.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/barthelemycc.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/barthelemycc.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=4480"}],"version-history":[{"count":4,"href":"https:\/\/barthelemycc.com\/index.php?rest_route=\/wp\/v2\/pages\/4480\/revisions"}],"predecessor-version":[{"id":4484,"href":"https:\/\/barthelemycc.com\/index.php?rest_route=\/wp\/v2\/pages\/4480\/revisions\/4484"}],"wp:attachment":[{"href":"https:\/\/barthelemycc.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=4480"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}