Instructions for Completing Net Worth Short Form Statement

Having been convicted in the United States District Court, you are required to prepare and file with the
probation officer an affidavit fully describing your financial resources, including a complete listing of all
assets you own or control as of this date and any assets you have transferred or sold since your arrest.

Amendments were made to 18 U.S.C. §§ 3663(a)(1)(B)(i), 3664(d)(3), and 3664(f)(2), and Rule 32(b)(4)(F)
to clarify that the assets owned, jointly owned, or controlled by a defendant, and liabilities are all relevant to
the court’s decision regarding the ability to pay. Your Net Worth Statement should include assets or debts
that are yours alone (I-Individual), assets or debts that are jointly (J-Joint) held by you and a spouse or
significant other, assets or debts that are held by a spouse or significant other (S-Spouse or Significant Other)
that you enjoy the benefits of or make occasional contributions toward, and assets or debts that are held by
a dependent (D-Dependent) that you enjoy the benefits of or make occasional contributions toward. The court
may require relating to such other factors as the court deems appropriate (see 18 U.S.C. § 3664(d)(3)).
If you are placed on probation or supervised release (or other types of supervision), you may be periodically
required to provide updated information fully describing your financial resources and those of your
dependents, as described above, to keep a probation officer informed concerning compliance with any
condition of supervision, including the payment of any criminal monetary penalties imposed by the court
(see 18 U.S.C. § 3603).

Please complete the Net Worth Short Form Statement in its entirety. You must answer “None” to any item
that is not applicable to your financial condition. Attach additional pages if you need more space for any
item. All entries must be accompanied by supporting documentation (see Request for Net Worth Statement
Financial Records (Prob. 48A)). Sign and date Page 2 (including any attached pages). Also, sign, date, and
attach the Declaration of Defendant or Offender Net Worth & Cash Flow Statements (Prob. 48D).