AMEDDApplicantWorksheet-July2012-3.doc

Had any foreign financial interests such as stocks

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had any foreign financial interests (such as stocks, property, investments, bank accounts, ownership of corporate entities, corporate interests or businesses) in which you or have direct control or direct ownership? (Exclude financial interests in companies or diversified mutual funds that are publicly traded on a U.S. exchange.) Parties involved: Yourself Spouse Cohabitant Dependent children Date acquired: Type (Bank Accounts, Financial Business, Other): Cost at time of acquisition in USD: Actual or Estimated? Current Value or Value at the time control or ownership was sold, lost or otherwise disposed of (in USD)? Actual or Estimated? Was control or ownership relinquished? Are there any co-owners of this foreign financial interest? 3. Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests that someone controlled on your behalf? Parties involved: Yourself Spouse Cohabitant Dependent children Date acquired: Type (Bank Accounts, Financial Business, Other): Cost at time of acquisition in USD: Actual or Estimated? Current Value or Value at the time control or ownership was sold, lost or otherwise disposed of (in USD)? Actual or Estimated? Was control or ownership relinquished? Are there any co-owners of this foreign financial interest? 4. Have you, your spouse, cohabitant, or dependent children EVER owned, or do you anticipate owning, or plan to purchase real estate in a foreign country? Parties involved: Yourself Spouse Cohabitant Dependent children Date acquired or to be acquired: Cost at time of acquisition in USD: Actual or Estimated? Type (Business, Land, Rental Property, Vacation Home , Other): How the real estate was/is to be acquired (such as purchase, gift, etc): Foreign owned real estate address: Street: City: Country: Was control or ownership relinquished? Are there any co-owners of this foreign financial interest? 37
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5. As a U.S. citizen, have you, your spouse, cohabitant, or dependent children received in the past seven (7) years , or are eligible to receive in the future, any educational, medical, retirement, social welfare, or other such benefit from a foreign country? Parties involved: Yourself Spouse Cohabitant Dependent children Type of benefit (Educational, medical, retirement, social welfare, other): Frequency of benefit (continuing, future, one-time, other): Country providing benefit: Value in USD: Actual or Estimated? As a result of this benefit are you, your spouse, your cohabitant, or dependent children obligated in any way to this foreign country? 6. Have you EVER provided financial support for any foreign national? Name of Person Extending Offer: Last First Middle Suffix Amount of all financial support provided: Actual or estimated: Frequency of support: Countries of Citizenship: Nature of relationship: Foreign national’s address: Street City: State: Country: 7. Have you in the past seven (7) years provided advice or support to any individual associated with a foreign business or other foreign organization that you have not previously listed as a former employer?
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