Registration No: 1026221

Registration No: 1026221 Person Number: 73274 Temporary Addresses O I do NOT have a temporary address Please nob: The registrant has reported additional temporary addresses not displayed here 1. 358 El Brillo Way (Street Address) Count), Palm Beath Palm Beath Oates you yell be at this address FL 33480-4730 (State) (ZO) From: 07/26/2012 To: Transient Addresses Oleo NOT have a transient *diens (SbeetAddre54 or lbeaban) County (Dry) Dates you will be at this address: From To: IS-aw) (Zip) Employment I am currently unemployed. 1. Employer Financial Trust Company Address: 000 Red Nook Quarter Ste B3 (Steel morass> CamtY Saint Thomas Occupation Owner St Thomas 104)1 Contact Person Stan Dale 07/26/2012 VI 00802 IS:a(e) (bpi Mailing Address O Same as Permanent O semen Temporary Phone Numbers Please not*. The reghltrant has sported additional not displayed here. O I do NOT have or use any borne or moods phone numbers 9 E 71st St i 2 3. 4. 5 7-0- , Nu-nbc' Phone Type: `tome (erns late 1) Mobile (Aridness Line 2) New YOM NY 10021 Fax (OILY) Costly. New York . rah) G5e/ Ens oar l'i'ork =az Campus Activity CI I am NOT • student, employes. et Volimilleie al a university or institution of higher learning. 1. O Slude- K Enicoyee UnnersitySchool Name: Address. County Voluntecrr Stan Date (Street Arktrattis) Employer. Campus End Date (Cry) Contact (Skye) (Zip) Professional Licenses I do NOT hare any professional licenses. 1. (Number) TyPe) issued by, Page 2 of EFTA00313896