United States Information

STATEMENT OF INFORMATION

(Confidential Information For Your Protection)

Statement of Information Printed: 06.11.24 @ 01:04 PM by EJ SSCORPD5699.doc / Updated: 03.29.24 Page 1 NV-CT-FANV-01313.420016-240160842 Escrow No.: 240160842

Completion of this Statement of Information assists in establishing identity, eliminating matters affecting persons with similar names and avoiding the use of fraudulent or forged documents. Complete all blanks (please print) or indicate

“none” or “N/A”. If more space is needed for any item(s), use the last page of the form. Each party (and spouse/domestic partner, if applicable) to the transaction must personally sign this form. PARTY TO TRANSACTION

Birth date

First Name Middle/Maiden Name Last Name

Personal Phone Business Phone Birthplace

City/State/Country

Social Security No.

List any other names (first and/or last) you have used or been known by State of Residence I have lived continuously in the United States since (date) If currently married, date and place (city/state) of marriage Residences (Last 10 years)

Number & Street City/State From (date) to (date)

Number & Street City/State From (date) to (date)

(if more space is required, use last page of form) Occupations/Businesses (Last 10 years)

Occupation Firm/Business Address From (date) to (date) Occupation Firm/Business Address From (date) to (date)

(if more space is required, use last page of form) CURRENT SPOUSE/DOMESTIC PARTNER

Birth date

First Name Middle/Maiden Name Last Name

Personal Phone Business Phone Birthplace

City/State/Country

Social Security No.

List any other names (first and/or last) you have used or been known by State of Residence I have lived continuously in the United States since (date) STATEMENT OF INFORMATION

(continued)

Statement of Information Printed: 06.11.24 @ 01:04 PM by EJ SSCORPD5699.doc / Updated: 03.29.24 Page 2 NV-CT-FANV-01313.420016-240160842 If currently married, date and place (city/state) of marriage Are you currently a registered domestic partner? Yes No Current Spouse/Domestic Partner Residences (Last 10 years) Number & Street City/State From (date) to (date)

Number & Street City/State From (date) to (date)

(if more space is required, use last page of form) Spouse or Domestic Partner - Occupations/Businesses (Last 10 years) Occupation Firm/Business Address From (date) to (date) Occupation Firm/Business Address From (date) to (date)

(if more space is required, use last page of form) PRIOR MARRIAGES

Any prior marriages for either spouse? Yes No

Prior spouse's name Prior spouse of

Marriage terminated on (date) by Death Divorce Prior spouse's name Prior spouse of

Marriage terminated on (date) by Death Divorce

(if more space is required, use last page of form) PRIOR DOMESTIC PARTNERSHIPS

Any prior domestic partnerships for either person? Yes No Prior partner's name Prior partner of

Partnership terminated on (date) by Death Dissolution Nullification Termination Prior partner's name Prior partner of

Partnership terminated on (date) by Death Dissolution Nullification Termination

(if more space is required, use last page of form) INFORMATION ABOUT THE PROPERTY

Buyer intends to reside on the property in this transaction: Yes No (to be answered by the Buyer only, otherwise, leave blank)

Property Owner to complete the following items

Property street address:

Property type: Unimproved Single or 1-4 family residential Condominium unit Other STATEMENT OF INFORMATION

(continued)

Statement of Information Printed: 06.11.24 @ 01:04 PM by EJ SSCORPD5699.doc / Updated: 03.29.24 Page 3 NV-CT-FANV-01313.420016-240160842 Have any improvements, remodeling or repairs been made to the property within the past six months? Yes No If yes, have all costs for labor and materials for such improvements been paid in full? Yes No Are there any outstanding loans on the property? Yes No Lender:

Loan No.:

Loan Date:

Original loan amount:

Lender:

Loan No.:

Loan Date:

Original loan amount:

By signing below, I declare under penalty of perjury, that the information provided by me on this form is true and correct. IN WITNESS WHEREOF, the undersigned have executed this document on the date(s) set forth below.

am pm

Signature Date Time

Print Name

am pm

Signature Date Time

Print Name

(Note: If applicable, both spouses/domestic partners must sign) ADDITIONAL INFORMATION

Contact this candidate