RAYMOND E. MCKOWN (CA Bar # 150975)
Federal Trade Commission
10877 Wilshire Blvd., Suite 700
Los Angeles, CA 90024
(310) 824-4343; Fax (310) 824-4380

JOSÉ DE JESUS RIVERA
United States Attorney

SUZANNE CHYNOWETH (Arizona Bar #6835)
Assistant United States Attorney
230 North 1st Avenue, Room 4000
Phoenix, Arizona 85025
(602) 514-7500

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA

FEDERAL TRADE COMMISSION, Plaintiff,

vs.

CAPITAL CARD SERVICES, INC., and CORY M. HARRIS, individually and as an officer of Capital Card Services, Inc., Defendants.

CIV 00 1993 PHX EHC

STIPULATION FOR ENTRY OF FINAL JUDGMENT AND ORDER FOR PERMANENT INJUNCTION AGAINST CAPITAL CARD SERVICES, INC., AND CORY M. HARRIS

Plaintiff, the Federal Trade Commission ("Commission"), and defendants Capital Card Services, Inc. ("CCS"), and Cory M. Harris hereby stipulate and agree to entry of a final judgment and order for permanent injunction against the defendants under the terms stated herein. This stipulation and the accompanying Final Judgment and Order for Permanent Injunction Against Capital Card Services Inc., and Cory M. Harris ("Order") resolve all matters raised by the Complaint the Commission filed against defendants on October 23, 2000, pursuant to Sections 13(b) and 19 of the Federal Trade Commission Act, 15 U.S.C. §§ 53(b) and 57b, and the Telemarketing and Consumer Fraud and Abuse Prevention Act, 15 U.S.C. §§ 6101 et seq., which charged defendants with violating Section 5(a) of the FTC Act, 15 U.S.C. 45(a), and the FTC's Telemarketing Sales Rule, 16 C.F.R. Part 310.

The Summons and Complaint having been served on defendants, plaintiff Commission and defendants request that the Court enter the accompanying Order with the following terms to resolve all matters of dispute between them in this action:

FINDINGS

1. This Court has jurisdiction of the subject matter of this case and of the parties consenting hereto;

 

2. Venue is proper as to all parties in the District of Arizona;

 

3. The activities of the defendants are in or affecting commerce, as defined in the Federal Trade Commission Act ("FTC Act"), 15 U.S.C. § 44;

 

4. The Complaint states a claim upon which relief may be granted against defendants under Sections 5(a), 13(b), and 19 of the FTC Act, 15 U.S.C. §§ 45(a), 53(b), and 57b, and the Telemarketing Sales Rule ("TSR"), 16 C.F.R. Part 310;

 

5. The Commission and defendants stipulate and agree to entry of the Final Judgment and Order for Permanent Injunction Against Capital Card Services, Inc., and Cory M. Harris freely without coercion and without trial or final adjudication of any issue of fact or law, to settle and resolve all matters in dispute arising from the Complaint to the date of entry of the Order. By entering this stipulation defendants acknowledge that each understands the provisions of the Order and are prepared to abide by them, but do not admit any of the allegations set forth in the Complaint other than jurisdictional facts;

 

6. The defendants have waived all rights that may arise under the Equal Access to Justice Act, 28 U.S.C. § 2412, amended by Pub. L. 104-121, 110 Stat. 847, 863-64 (1996);

 

7. The defendants have also waived all rights to seek appellate review or otherwise challenge or contest the validity of this Order, and have further waived and released any claim they may have against the Commission, its employees, and agents; and

 

8. Entry of this Order is in the public interest.

IT IS HEREBY ORDERED, ADJUDGED AND DECREED as follows:

DEFINITIONS

1. "Defendants" mean Capital Card Services, Inc., and Cory M. Harris, their successors and assigns, and their officers, agents, servants, employees, attorneys, and those persons in active concert or participation with them who receive actual notice of this order by personal service or otherwise.

 

2. "Consumer" means a purchaser, customer, subscriber, or natural person.

 

3. "Telemarketing" means a plan, program, or campaign that is conducted to induce the purchase of goods or services by use of one or more telephones and involves more than one interstate telephone call made to or from any customer, provided however, that "telemarketing" does not include telephone calls in which the sale of goods or services is not completed, and payment or authorization of payment is not required, until after a face-to-face sales presentation by the seller.

 

4. "Credit Card Protection" means the advertisement, promotion, offering for sale, or sale of any product or service represented to register credit or debit accounts, including credit card accounts, or protect, indemnify, or reimburse the holder of a credit or debit account against unauthorized use or charges.

I.

BAN ON SELLING OR MARKETING CREDIT CARD PROTECTION

IT IS FURTHER ORDERED that defendants are permanently restrained and enjoined from engaging in, receiving any remuneration of any kind whatsoever from, holding any ownership interest, share, or stock in, serving as an officer, director, trustee of, or consultant or advisor to, any business entity engaged in, in whole or in part, credit card protection services.

II.

PROHIBITED BUSINESS PRACTICES

IT IS FURTHER ORDERED that defendants, in connection with the sale of any product or service, are hereby restrained and enjoined from:

A. Misrepresenting an affiliation with a consumer's credit card company or issuer, financial institution, or any other third party;

 

B. Representing that any consumer is liable for unauthorized charges on his or her credit card accounts in excess of the $50 limit set forth in 15 U.S.C. § 1643 and 12 C.F.R. § 226.12(b);

 

C. Misrepresenting that a consumer has purchased or has agreed to purchase any good or service, and therefore owes money to the seller;

 

D. Misrepresenting the amount or frequency of required installment payments;

 

E. Failing to comply with the TSR, 16 C.F.R. Part 310, as attached hereto as Attachment A, or as subsequently amended;

 

F. Making any material misrepresentation about a consumer's credit-related rights or obligations under the law;

 

G. Misrepresenting that any consumer has been pre-approved for, or is likely to obtain, an extension of credit; and

 

H. Misrepresenting any other fact material to a consumer's decision to purchase a good or service.

III.

BOND PROVISION

IT IS FURTHER ORDERED THAT:

A. Each defendant is enjoined from engaging, whether directly, in concert with others, or through any business entity, in the telemarketing of any product(s) or service(s), unless said defendant first obtains a performance bond in the principal sum of $200,000 (two-hundred thousand dollars).

 

B. The terms and conditions of the bond requirement in Paragraph A, above, shall be as follows:

 

1. The bond is conditioned upon compliance by said defendant with Section 5(a) of the FTC Act, 15 U.S.C. §§ 45;

 

2. The bond shall remain in full force and effect as long as said defendant continues to engage in the telemarketing of any product(s) or service(s), and for at least three (3) years thereafter;

 

3. The bond shall be an insurance agreement providing surety for financial loss that is issued by a surety company (1) admitted to do business in each state in which said defendant does business and (2) that holds a Federal Certificate of Authority As Acceptable Surety On Federal Bond and Reinsuring;

 

4. The bond shall be in favor of the Federal Trade Commission for the benefit of any party injured as a result of any deceptive misrepresentation or violation of this Order;

 

5. Said defendant shall provide written notice and proof of the bond to the Federal Trade Commission at least ten (10) days before the commencement of the activity for which the bond is required; and

 

6. The bond required by this Order shall be in addition to, and not in lieu of, any bond required by federal, state, or local law, or the order of another court.

IV.

ENFORCEMENT OF CONTRACTS

IT IS FURTHER ORDERED that defendants are hereby permanently restrained and enjoined from demanding payment on or enforcing or threatening to enforce any contract or agreement, which purports to sell credit card protection to consumers, entered into by either defendant prior to the effective date of this Order.

V.

DISTRIBUTION OF CUSTOMER RECORDS

IT IS FURTHER ORDERED that defendants are hereby permanently restrained and enjoined from providing to any person, except agents of the Commission or other law enforcement authorities, the name, address, telephone number, or credit card or bank account number of any consumer who provided such information to or did business with defendants; provided, however, that defendants may provide such information if required to do so by court order.

VI.

CONSUMER REDRESS

IT IS FURTHER ORDERED that:

A. Judgment is hereby entered against defendant Capital Card Services, Inc., in the amount of $2,000,000 (two million dollars);

 

B. Defendant Capital Card Services, Inc. shall assign and transfer to the Commission, or to its designated agent, all rights, title, and interest in any and all funds due to defendant Capital Card Services, Inc., or received by it at any time from any source, including but not limited to, Clickpay LLC, KLEline S.A., BNP Paribas, any credit card processor, or any other business entity or person, in connection with the sale of any product or service, including, but not limited to, credit card protection services, debt consolidation services, or low interest credit cards sold or marketed by Capital Card Services, Inc., or Cory M. Harris, through any business entity, including, but not limited to, Cory M. Harris dba Capital Card Services;

 

C. Judgment is hereby entered against defendant Cory M. Harris in the amount of $ 4,790 (four thousand seven hundred ninety dollars).

 

D. Defendant Cory M. Harris shall assign and transfer to the Commission, or to its designated agent, all rights, title, and interest in any and all funds due to defendant Cory M. Harris from any source, or received by him at any time from any source, including, but not limited to, Clickpay LLC, KLEline S.A., BNP Paribas, any credit card processor, or any other business entity, in connection with the sale of any credit card protection services, debt consolidation services, or low interest credit card services, through any business entity, including, but not limited to, Cory M. Harris dba Capital Card Services;

 

E. The consumer redress judgments set forth in Paragraphs A through D of this Section are hereby entered in favor of the Commission for equitable monetary relief, including but not limited to, consumer redress and/or disgorgement, and for paying any attendant expenses of administering any redress fund;

 

F. If the Commission, in its sole discretion, determines that redress is wholly or partially impractical, any funds not so used shall be deposited in the United States Treasury. The Commission in its sole discretion may use a designated agent to administer consumer redress. This judgment for equitable monetary relief is solely remedial in nature and is not a fine, penalty, punitive assessment, or forfeiture. The Commission shall have full and sole discretion to:

 

1. Determine the criteria for participation by individual claimants in any consumer redress program implemented pursuant to this Order;

 

2. Determine the manner and timing of any notices to be given to consumers regarding the existence and terms of such programs; and

 

3. Delegate any and all tasks connected with such redress program to any individuals, partnerships, or corporations; and pay the fees, salaries, and expenses incurred thereby from the payments made pursuant to this Order;

 

G. Defendants shall provide the Commission, or its agent, within thirty (30) days of such a request, the name, last known address, telephone number, date of purchase, credit card or bank account information, and the complete file record, including computer records and correspondence, of each consumer who paid defendants for a credit card protection product or service from January 1, 1999, through the date this Order is entered, as well as any further information the Commission deems necessary to effectuate a consumer redress program;

 

H. Each defendant shall also furnish to the Commission, in accordance with 31 U.S.C. § 7701, their taxpayer identification number (social security number, social insurance number, employer identification number, or Revenue Canada identification number), which shall be used for purposes of collecting and reporting on any delinquent amount arising out of each defendant's relationship with the government; and

 

I. Any redress administrator shall destroy all records relating to this matter six years after the transfer of any remaining redress funds to the FTC Treasury account or the closing of the account from which such funds were disbursed, whichever is earlier, provided that no records shall be destroyed unless and until a representative of the Commission has received and approved the administrator's final accounting report. Records shall be destroyed in accordance with disposal methods and procedures to be specified by the Commission. The Commission may, in its sole discretion, require that such records, in whole or in part, be transferred, in lieu of destruction, to the Commission.

VII.

RELIANCE ON DISCLOSURES

IT IS FURTHER ORDERED that the Commission's agreement to this Order is expressly premised upon the truthfulness, accuracy, and completeness of the financial condition of each defendant, as represented in their respective financial statements dated 10/27/2000 (CCS), and 10/27/2000  (Harris), and submitted documents listed in Attachment B, upon which the Commission relied in negotiating and agreeing to the amount of consumer redress and the other terms of this Order. If, upon motion by the Commission, this Court finds that either defendant failed to file the sworn statement required by Section XIV, or filed a financial statement that failed to disclose any material asset, or materially misrepresented the value of any asset, or made any other material misrepresentation in or omission from the financial statement or documents listed in Attachment B, the Court shall enter judgment against defendant Harris, in favor of the Commission, in the amount of two million dollars ($2,000,000), which is intended to represent the total loss to consumers or unjust enrichment obtained by defendants, and which will become immediately due and payable. For purposes of this Section, and any subsequent proceedings to enforce payment, including but not limited to a non-dischargeability complaint filed in a bankruptcy proceeding, defendants waive any right to contest any allegations in the Commission's Complaint.

VIII.

MONITORING COMPLIANCE OF SALES PERSONNEL

IT IS FURTHER ORDERED that defendants, in connection with any business where (1) either defendant is the majority owner of the business or directly or indirectly controls the business and where (2) the business is engaged in telemarketing, or indirectly uses telemarketing as a means of achieving sales, are hereby permanently restrained and enjoined from:

A. Failing to take reasonable steps sufficient to monitor and ensure that all employees and independent contractors engaged in sales or other customer service functions comply with the restrictions placed on defendants by Sections I - V of this Order, the FTC Act, and the TSR. Such steps shall include adequate monitoring of sales presentations or other calls with customers, and shall also include, at a minimum, the following:

 

1. Listening to oral representations made by persons engaged in sales or other customer service functions;

 

2. Establishing a procedure for receiving and responding to consumer complaints;

 

3. Ascertaining the number and nature of consumer complaints regarding transactions in which each employee or independent contractor is involved; provided that this Section does not authorize or require defendants to take any steps that violate any federal, state, or local laws;

 

B. Failing to promptly and fully investigate any consumer complaint received by any business to which this Section applies; and

 

C. Failing to take corrective action with respect to any sales person whom defendants determine is not complying with the conditions stated in this Order. Such corrective action may include training, disciplining, or terminating such sales person.

IX.

RECORD KEEPING PROVISIONS

IT IS FURTHER ORDERED that, for a period of five (5) years from the date of entry of this Order, defendants, in connection with any business where (1) either defendant is the majority owner of the business or directly or indirectly controls the business and where (2) the business is engaged in telemarketing, or indirectly uses telemarketing as a means achieving sales, are hereby restrained and enjoined from failing to create, and from failing to retain for a period of three (3) years following the date of such creation, unless otherwise specified:

A. Books, records and accounts that, in reasonable detail, reflect the cost of goods or services sold, revenues generated, and the disbursement of such revenues;

 

B. Records that reflect: the name, address, and telephone number of each person employed in any capacity, including those employed as an independent contractor; the person's job or position; the date upon which the person commenced work; and the date and reason for the person's termination, if applicable. The businesses subject to this Section shall retain such records for any terminated employee for a period of two (2) years following the date of termination;

 

C. Records that reflect: the names, addresses, phone numbers, dollar amounts paid, quantity of items or services purchased or provided, and a description of items or services purchased or provided, for all consumers who purchased items or services from defendants;

 

D. Records that reflect, for every consumer complaint or refund request, whether received directly or indirectly or through any third party:

 

1. The consumer's name, address, and telephone number and the dollar amount paid by the consumer;

 

2. The written complaint or refund request, if any, and the date of the complaint or refund request;

 

3. The basis of the complaint, including the name of any salesperson complained against, and the nature and result of any investigation conducted concerning the complaint;

 

4. Each response and the date of the response;

 

5. Any final resolution and the date of the resolution; and

 

6. In the event of a denial of a refund request, the reason for the denial; and

 

E. Copies of all sales scripts, training materials, advertisements, or other marketing materials utilized; provided that copies of all sales scripts, training materials, advertisements, or other marketing materials utilized shall be retained for three (3) years after the last date of dissemination of such materials.

X.

COMPLIANCE REPORTING BY DEFENDANTS

IT IS FURTHER ORDERED that, in order that compliance with the provisions of this Order may be monitored:

A. For a period of five (5) years from the date of entry of this Order, defendants shall notify the Commission of the following:

 

1. Any changes in Harris's residential addresses and telephone numbers within ten (10) days of such change;

 

2. Any changes in employment status (including self employment) within ten (10) days of such change. Such notice shall include the name, mailing and physical location addresses, and telephone number of each business the defendant is affiliated with or employed by, a statement of the nature of the business, and the duties and responsibilities in connection with the business or employment;

 

3. Any proposed change in the corporate structure of CCS, or any proposed change in the structure of any business entity owned or controlled by either defendant, such as creation, incorporation, dissolution, assignment, sale, merger, creation, dissolution of subsidiaries, proposed filing of a bankruptcy petition, or change in the corporate name or address, or any other change that may affect compliance obligations arising out of this Order, thirty (30) days prior to the effective date of any proposed change; provided, however, that with respect to any proposed change in a business entity about which either defendant learns of less than thirty (30) days prior to the date such action is to take place, the defendant shall notify the Commission as soon as is practicable after learning of such proposed change; and

 

4. An accounting of all funds received by either defendant in accordance with Sections VI. B. and VI. D. of this Order;

 

B. One hundred eighty (180) days after the date of entry of this Order, each defendant shall provide a written report to the Commission, sworn to under penalty of perjury, setting forth in detail the manner and form in which the defendant has complied and is complying with this Order. This report shall include but not be limited to:

 

1. The defendant's current residential address and telephone number;

 

2. Identification of the defendant's current employer, the employer's mailing and physical location addresses and telephone numbers, a description of the business activities of each such employer, and the responsibilities for each employer;

 

3. A copy of each acknowledgment of receipt of this Order obtained by the defendant pursuant to Section XIII; and

 

4. A statement describing the manner in which the defendant has complied and is complying with (a) the injunctive provisions of this Order (Sections I-V), and (b) the consumer redress provisions of this Order (Section VI);

 

C. Upon written request by a representative of the Commission, each defendant shall submit additional written reports (under oath, if requested) and produce documents on fifteen (15) days' notice with respect to any conduct subject to this Order;

 

D. For the purposes of this Order, each defendant shall, unless otherwise directed by the Commission's authorized representatives, mail all written notifications to the Commission to: Regional Director, Federal Trade Commission, 901 Market Street, Suite 570, San Francisco, CA 94103, or such other address as the Commission shall designate in writing;

 

E. For the purposes of this Section, "employment" includes the performance of services as an employee, consultant, or independent contractor; and "employers" include any individual or entity for whom any defendant performs services as an employee, consultant, or independent contractor; and

 

F. For purposes of the compliance reporting required by this Section, the Commission is authorized to communicate directly with defendants.

XI.

AUTHORITY TO MONITOR COMPLIANCE

IT IS FURTHER ORDERED that the Commission is authorized to monitor defendants' compliance with this Order by all lawful means, including but not limited to the following:

A. The Commission is authorized, without further leave of the Court, to obtain discovery from any person in the manner provided by Chapter V of the Federal Rules of Civil Procedure, Fed. R. Civ. P. 26 - 37, including the use of compulsory process pursuant to Fed. R. Civ. P. 45, for the purpose of monitoring and investigating defendants' compliance with any provision of this Order;

 

B. The Commission is authorized to use representatives posing as consumers or suppliers to either defendant, their employees, or any other entity owned or controlled in whole or in part by either defendant, without the necessity of identification or prior notice; and

 

C. Nothing in this Order shall limit the Commission's lawful use of compulsory process, pursuant to Sections 9 and 20 of the FTC Act, 15 U.S.C. §§ 49, 57b-1, to investigate whether either defendant has violated any provision of this Order, the FTC Act, or the TSR.

XII.

ACCESS TO BUSINESS PREMISES

IT IS FURTHER ORDERED that, for a period of five (5) years from the date of entry of this Order, for the purpose of further determining compliance with this Order, defendants shall permit representatives of the Commission, within three (3) business days of receipt of written notice from the Commission:

A. Access during normal business hours to any office, or facility storing documents, of any business where (1) either defendant is the majority owner of the business or directly or indirectly controls the business, and where (2) the business is engaged in telemarketing, or indirectly uses telemarketing as a means of achieving sales. In providing such access, defendants shall permit representatives of the Commission to inspect and copy all documents relevant to any matter contained in this Order; and shall permit Commission representatives to remove documents relevant to any matter contained in this Order for a period not to exceed five (5) business days so that the documents may be inspected, inventoried, and copied;

 

B. To interview the officers, directors, and employees, including all personnel involved in responding to consumer complaints or inquiries, and all sales personnel, whether designated as employees, consultants, independent contractors or otherwise, of any business to which Section XII. A. applies, concerning matters relating to compliance with the terms of this Order. The person interviewed may have counsel present; and

 

C. Upon application of the Commission and for good cause shown, the Court may enter an ex parte order granting immediate access to the business premises of either defendant for the purposes of inspecting and copying all documents relevant to any matter contained in this Order.

XIV.

DISTRIBUTION OF ORDER BY DEFENDANTS

IT IS FURTHER ORDERED that, for a period of five (5) years from the date of entry of this Order, defendants shall:

A. Provide a copy of this Order (excluding Attachments B and C) to, and obtain a signed and dated acknowledgment of receipt of same from, each officer or director, each individual serving in a management capacity, all personnel involved in responding to consumer complaints or inquiries, and all sales personnel, whether designated as employees, consultants, independent contractors or otherwise, immediately upon employing or retaining any such persons, for any business where (1) either defendant is the majority owner of the business or directly or indirectly controls the business, and where (2) the business is engaged in telemarketing, or where telemarketing is indirectly used as a means of achieving sales; and

 

B. Maintain for a period of three (3) years after creation, and upon reasonable notice, make available to representatives of the Commission, the original signed and dated acknowledgments of the receipt of copies of this Order, as required by sub-section (A).

XIV.

ACKNOWLEDGMENT OF RECEIPT OF ORDER BY DEFENDANTS

IT IS FURTHER ORDERED that within five (5) business days after receipt of this Order as entered by the Court each defendant shall submit to the Commission a truthful sworn and notarized statement, in the form shown on Attachment C, that shall acknowledge receipt of this Order as entered and shall reaffirm and attest to the truthfulness, accuracy, and completeness of that defendant's financial statement.

XV.

RETENTION OF JURISDICTION

IT IS FURTHER ORDERED that this Court will retain jurisdiction of this matter for the purpose of enabling any of the parties to this Order to apply to the Court at any time for such further orders or directives as may be necessary or appropriate for the interpretation or modification of this Order, for the enforcement of compliance therewith or the punishment of violations thereof.

Defendants and the Commission, through their respective counsel, hereby consent to the terms and conditions of this stipulation as set forth above and consent to the entry of an Order with the same terms.

DATED: , 2001

CORY M. HARRIS, individually and as
an officer of Capital Card Services, Inc.

DATED: , 2001

CAPITAL CARD SERVICES, INC., by
Cory M. Harris, its President

DATED: , 2001

JEROME M. STEINER, JR.
RAYMOND E. MCKOWN
Attorneys for Plaintiff
Federal Trade Commission

APPROVED AS TO FORM:

DATED: , 2001

RAND HADDOCK
Jennings, Strouss & Salmon, PLC
Attorney for Defendants
Capital Card Services, Inc., and
Cory M. Harris

ATTACHMENT A

ATTACHMENT A

TELEMARKETING SALES RULE

ATTACHMENT B

(List of Financial Documents)

1. Profit and Loss Statement for Cory Harris DBA Capital Card Services, Inc., January 1 through December 14, 2000, of three (3) pages.

 

2. Balance Sheet for Cory Harris DBA Capital Card Services, Inc. as of December 14, 2000.

 

3. Responses to items 20 through part of item 22 on the financial statement form submitted to the FTC on January 17, 2001, identified as deposition exhibit 7.

ATTACHMENT C

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA

FEDERAL TRADE COMMISSION,  Plaintiff,

vs.

CAPITAL CARD SERVICES, INC., and CORY M. HARRIS, individually and as an officer of Capital Card Services, Inc., Defendants.

CV No. 00 1993 PHX EHC

AFFIDAVIT OF [DEFENDANT

[Defendant], being duly sworn, hereby states and affirms as follows:

1. My name is . My current residence address is (list street, city state, zip code, country) . I am a citizen of the United States and am over the age of eighteen. I have personal knowledge of the facts set forth in this Affidavit.

2. I am a defendant in FTC v. Capital Card Services, Inc. et al. CV. 00 - 1993 EHC (United States District Court for the District of Arizona).

3. On , 2001, I received a copy of the Final Judgment and Order for Permanent Injunction Against Defendants Capital Card Services, Inc. and Cory M. Harris, which was signed by the Honorable [name of U.S. District Judge] and entered by the Court on , 2001. A true and correct copy of the Order I received is appended to this Affidavit.

4. I hereby state that the information contained my financial statement, as identified in paragraph VIII of the Order, which was executed signed on , and provided to the Federal Trade Commission shortly thereafter was true, accurate, and complete at such time.

I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct. Executed on , 2001, at [place].

____________________________
[Name of Defendant & signature]

State of ____________________, City of ____________________

Subscribed and sworn to before me this _____ day of , 2001.

_____________________________
Notary Public
My Commission Expires:

_____________________________