XGR Dubas SFI

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    - NEBRASKA -( ) 1 jPOSTMARK cjJJ!j, -ACCOUNTABILITY AND DATE !DISCLOSURE COMMISSION STATEMENT MICROFILM 796(}09~ j11th Floor, State Capitol NUMBEROF.o. Box 95086 OFFICEilf~-Q~~ y,,.. "-Lincoln, NE 68509 FINANCIAL L . ! N G o 'L T ! , Y i i ' t t ~ \ S i { l(402) 471-2522 INTERESTS 7 0 0 ',ll0 ,) IBEFORE COMPLETING 10-1..\)-1 fU-in v , P H 2 : 1 5READ FILING REQUIREMENTS ' . D 'i~ C C 'i . f N i / i ~ ' I ; : . , J IT Y t.NADC FORM C-1 lJ. ..'i\_ CU''''"'!i

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    "rrEMJ8 I REAL PROPERTY OF T~_)ILER IN NEBRASKA (Real property vdl,jd at less than $1,000 and yourpersonal residence need notbe reported.) ....List all real propertyin your name or inwhich you have a direct ownership interest. The description required must be sufficient to identthe location .of the property. Exceptions: You need not report real estate owned by a business listed in Item 6 or 7, your personresidence of real property valued at less than $1,000. Personal residence refers to your principal dwell ing-house and adjacent land usefor house-hold purposes, such as lawns and qardens.

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    Nature of Property(such as: agricultural, commercial, industrial, residential-rental)Location of Property(Description or Address

    ITEM 9 I OTHER FINANCIAL INTEREST.$ AND PROPERTY HELODURINGTHE PE.RIOD OF THIS STATEMENTWHICH EXCEEDED A FAIR MARKET VALUE OF $1,000 AT ANY TIME DURING THE REPORTING PERIOD(a) Listthe names and addresses of the inst itutions in which you had checking and savings accounts and certificates of deposit.

    Financial Institution AddressJ30 =rtFu.((v1b-n .4 - 1 1 b Bl"OA.c iWIl .1 ' fu .11u-h"h

    ~1d.1 Arc. .her R . l ) A-rc..htr, N E

    (b) List the names of the issuers of all stocks, bonds, and government securities, not otherwise listed under Items 6 or 7.

    (c) Describe other property owned or held for the production of income not otherwise disclosed in Items 6, 7,8 or 9(a)(b). Includeleaseholds and other interests in real estate, promissory notes and other obligations owed to you, beneficial interests in trusts andestates, cash value life insurance, IRAs, deferred income and retirement plans. Exception: Do not include accounts receivable,inventory, fixtures and equipment owned or used by a business listed in Items 6 & 7 or household goods, personal automobiles andother tanolble personal property unless such property was held primarily for sale or exchance.

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    . . ()" ~ITEM 10 I CREDITORS TO WHOM $1,000 OR MORE WAS OWED OR GUARANTEED BY YOU OR A MEMBER OFYOUR IMMEDIATE FAMILY.

    Exception: Loans from a relative and land contracts which have been recorded with the County Clerk or Register of Deeds need not bereported. Accounts payable, debts arising out of retail installment transactions or loans made by a financial institution in the ordinarycourse of business need not be reported.Name Address

    I

    ITEM 11 I SOURCES OF GIFTS OF A VALUE OF MORE THAN $100 RECEIVED EXCEPT GIFTS FROM RELATIVES.(See definitions)Name and address of Donor Occupation or nature of business of Value of Gift Description of Gift andDonor (See Key Below) Circumstances or Occasion forGift~iver'I+~ of Nwa.sl